When Joe Lex makes his “pick of the week” on Free Emergency Medicine Talks you know its worth listening to. This week’s pick is exceptional. It’s a talk by Bart Besinger, an emergency physician from Indiana, who delivers an excellent current review on the medical management of the severe brain injured patient in the emergency department.
Listen to Bart’s talk for free here: Fine-tuning care of the injured brain.
Many patients with severe brain injury will succumb to their injuries. However, there is a subset of patients for whom optimal early management has a profound impact on their prognosis. If we do things right, some patients have a chance of actually walking out of hospital alive with good neurological function.
The care we provide for the brain injured patient is not always about the big things we do, but more about the little things we do that can make the difference. Here is a ‘key points’ summary of Bart Besinger’s talk:
Bart Besinger’s Top 5 little things we can do in the ED
- Elevating the head of the bed to 30° — will decrease ICP via displacing the CSF and increasing venous outflow.
- By elevating the head of the bed to between 30°-45° also decrease the risk of developing ventilator associated pneumonia.
- However elevating the head of the bed can be difficult in the patient with spinal precautions.
- Bart also recommends avoiding the trendelenburg position (especially when inserting central lines) as this intervention offer’s little benefit but can greatly increase the ICP.
- C-Spine collar aka “The Brain Tourniquet”.
- Clearing the cervical spine of these patients can often be difficult in the comatosed intubated patient.
- Removal of the C-spine collar has been showen to decrease ICP by around 2-5 mmHg.
- If you are unable to remove the cervical collar check the position, size and tightness of the collar. Bart’s tip: loosen it up a bit so it aids venous return but still supports the head.
Blood Sugar Control
- This part of talk gets controversial — the key point is you need to find the right balance for managing the blood glucose level in these patients.
- Patients with severe brain injury and hyperglycaemia have an increased mortality, and have poorer neurological outcomes. However research has been unable say if this is a marker of severe injury, or a cause of secondary brain injury.
- Remember hypoglycaemia is bad in the severe brain injured patient — the brain is an obligate glucose consumer and needs sugar to function.
- Studies show intensive insulin therapy results in more episodes of hypoglycaemia and may even increase mortality.
- Bart’s taken home point for managing the blood sugar: don’t aim for strict low blood sugar control… Aim to keep the BSL between 8-12 mmol/L.
- Therapeutic hypothermia has shown great improvement in the cardiac arrest victims, however for the injured brain: “There is no evidence that hypothermia is beneficial in the treatment of head injury”
- Therapeutic hypothermia in the injured brain has resulted in more cases of coagulopathy, pneumonia and sepsis.
- Bart’s recommends we should focus on “therapeutic normothermia” for these patient’s we know cooling is bad, but also fevers and hyperthermia is also detrimental as well.
- We know fever increases cerebral metabolic rate and oxygen consumption with associated poor outcomes, however there is currently no good outcome studies to support this.
- Take home point: fevers can develop quickly (yes even while the patient is still in ED), so monitor closely and treat aggressively.
Blood Pressure Management
- Patients with a severe brain injury often present with an abnormal blood pressure.
- Hypotension is profoundly detrimental to these patient and needs to be treated aggressively to maintain cerebral perfusion pressure.
- Hypertension can occur through the underlying physiological response to raised ICP, due to an underlying medical condition or may be related to pain and anxiety.
- Treatment is generally not recommended in the hypertensive patient, remember these patients require sedatives and analgesia when intubated — providing this can relieve some of the hypertension.
- On the rare occasion that you have to treat the high blood pressure, use short acting anti-hypertensive only and dose very gingerly.
- Keep the patients head up — decreases ICP &VAP.
- Check the collar — remove if possible to reduce ICP.
- Treat patients with marked hyperglycaemia but avoid hypoglycaemia.
- Cooling doesn’t work, but avoid hyperthermia at all cost.
- Don’t worry too much about the high blood pressure, but be very concerned about low blood pressure.
- Severe Traumatic Brain Injury – Crashingpatient.com
- Flower O, Smith M. The acute management of intracerebral hemorrhage. Current Opinion in Critical Care. 2011;17:106-114. PMID: 21169826.
- Mittal R. Critical care in the emergency department; traumatic brain injury. Emergency Medicine Journal. 2009;26:513-517. PMID: 19546274.