For patients unable to liberate from ventilator support, or deemed not likely to improve rapidly, a tracheostomy tube should be considered, ideally within 8 day of initial injury. It is recommended the tracheostomy be held off until persistently elevated ICPs, hemodynamic instability, and severe respiratory failure have resolved [3]. Similarly, non-intracranial procedures should be delayed until neurological status is stable. Orthopaedic surgeries should be delayed 24–48 h after ICP stabilization.
Intravenous anaesthesia is preferred over regional techniques in the setting of intracranial hypertension. Anaesthesia should be monitored closely to prevent intracranial hypertension, hypoten- sion, hypoxia, and hypo or hypercarbia [3].
VTE is common in the TBI population. Nearly 20–30% of TBI patients develop venous thromboembolism (VTE); therefore, VTE prophylaxis should be initiated once intracranial bleeding has stopped. Inferior vena cava filters may be considered in patients that cannot receive pharmacologic prophylaxis [3].
Paroxysmal sympathetic hyperactivity (PSH) is thought to occur in 15–33% of comatose patients with severe brain injury. PSH is a diagnosis of exclusion characterized by the rapid onset and parox- ysmal cycling of agitation and dystonia associated with autonomic symptoms including: tachycardia, hypertension, tachypnea, fever, pupil dilation, decreased level of consciousness, diaphoresis, and ventilator dyssynchrony. The pathophysiology of PSH continues to be poorly understood. When the parasympathetic feedback mecha- nism fails, sympathetic outflow is uninhibited; leading to hyperac- tivity and ultimately PSH. Pharmacologic therapy aims to inhibit afferent sensory processing to limit the development of allodynia, inhibit central sympathetic outflow, and block end organ responses of the sympathetic nervous system. Medications are used to target specific cell surface proteins, including voltage gated calcium chan- nels, GABA A and GABA B receptors, alpha and beta-adrenergic receptors, dopamine receptors, and opiate receptors [21].
References
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Summary Points
• ICU care of the TBI patient revolves around monitoring and supportive care, with the goal of pre-empting or preventing secondary cerebral injury.
• There is no effective drug treatment for TBI; however, improvements in pre-hospital care, advanced imaging techniques and adherence to guidelines have been asso- ciated with improved outcomes.
9. Nangunoori R, Maloney-Wilensky E, et al. Brain tissue oxygen-based therapy and outcome after severe traumatic brain injury: a systematic literature review. Neurocrit Care. 2012;17:131–8.
10. Beynon C, Kiening K, Orakcioglu B, et al. Brain tissue oxygen moni- toring and hyperoxic treatment in patients with traumatic brain injury.
J Neurotrauma. 2012;29:2109–23.
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13. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58:S16.
14. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of pos- terior fossa mass lesions. Neurosurgery. 2006;58:S47.
15. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of depressed cranial fractures. Neurosurgery. 2006;58:S56.
16. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas. Neurosurgery. 2006;58:S7.
17. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of trau- matic parenchymal lesions. Neurosurgery. 2006;58:S25.
18. Hartl R, Gerber LM, Ni Q, Ghajar J. Effect of early nutrition on deaths due to severe traumatic brain injury. J Neurosurg. 2008;109:50–6.
19. Clifton GL, Valadka A, Zygun D, et al. Very early hypothermia induc- tion in patients with severe brain injury (the National Acute Brain Injury Study: hypothermia II): a randomised trial. Lancet Neurol.
2011;10(2):131–9.
20. Wright DW, Yeatts SD, Silbergleit R, et al. Very early administra- tion of progesterone for acute traumatic brain injury. N Engl J Med.
2014;371(26):2457–66.
21. Lump D, Moyer M. Paroxysmal sympathetic hyperactivity after severe brain injury. Curr Neurol Neurosci Rep. 2014;14(494):1–7.
doi:10.1007/s11910-014-0494-0.
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J.L. White, K.N. Sheth (eds.), Neurocritical Care for the Advanced Practice Clinician, DOI 10.1007/978-3-319-48669-7_11
Intracranial Pressure Management
Danielle Bajus and Lori Shutter