Severe Traumatic Brain Injury with Dr. Dana Klavansky

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Sam: I actually wouldn't consider
that to be mild in general
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practice if somebody said they were
actually out for 25 minutes or so.
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But 30 minutes is the general
accepted guideline there.
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Sam : Hi everyone, and welcome
to another episode of EMPlify
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I'm your host, Sam Ashoo.
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Before we dive into this month's episode,
I want to say thank you for joining us.
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I sincerely hope that you find it to
be helpful and informative for your
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clinical practice, and I want to remind
you that you can go to ebmedicine.net
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where you will find our three journals,
Emergency Medicine Practice, Pediatric
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Emergency Medicine Practice, and Evidence
Based Urgent Care, and a multitude of
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other resources, like the EKG course,
the laceration course, interactive
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clinical pathways, just tons of
information to support your practice
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and help you in your patient care.
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And now, let's jump into
this month's episode.
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Sam: All right.
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Welcome back to the podcast everyone.
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Today we have a special guest, one of
the authors of the March, 2026 article
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on severe traumatic brain injury.
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This is Dr. Klavansky and
I'm gonna let her tell you a
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little bit more about herself.
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Welcome to the show.
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Dana: Thank you for having me.
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So, yeah.
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My name is Dr.
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Dana Klavansky.
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I'm one of the neurointensivists
at the Mount Sinai Hospital.
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And me and my co-fellow wrote this
article to really expand our knowledge,
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our group's knowledge, and to just
give the emergency medicine community
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also a comprehensive review of what it
means to treat severe TBI patients and.
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In the safest way with the
latest literature review.
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So we're really happy
with how it turned out.
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Sam: Yeah, I think it's a fantastic
issue and I'm excited for everyone
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listening to go and read it.
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It's packed full of information tables and
figures lots of images, which I love, and
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, it's an excellent review of the topic.
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Now you, as one of the co-authors,
you have a special interest in this.
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You see a lot of this in
your day-to-day practice.
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Dana: So we actually
don't see too much of it.
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At our, one of our affiliate
hospitals, Elmhurst is where most
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of the neuro traumas actually go to,
and also to Mount Sinai Morningside.
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But Mount Sinai Hospital itself
and Mount Sinai West where I work,
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don't really see too many of them.
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So this was actually even more
interesting to write in that regard
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because, you know, we got to learn
through this process also and learn.
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What the latest practices
are and things like that.
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So, it was really
interesting to write this.
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Sam: Great.
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Great.
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And let's talk more about severe
traumatic brain injury as an entity.
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So how common is it and how
often do we see it in the US?
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Dana: Yeah, so every year there's
almost like 2 million traumatic
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brain injuries to some degree.
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Severe TBIs are not as common.
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Thankfully, most people do get
discharged from the hospital and
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they end up doing really well.
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But there is a certain
population, especially those
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that are a bit more rogue.
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You know, our 15 to 19 year olds , and
then our older population who, you know,
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just has a higher propensity to fall
and hurt themselves, and then they're
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on blood thinners and all those other
things that can cause severe brain injury.
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It's thankfully a smaller population, but
it's in the hundreds of thousands every
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year that people develop severe TBIs.
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Sam: So our, our teens and
then our elderly population.
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And is there a gender
distribution there as well?
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Dana: Yeah.
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So as kind of maybe anticipated men
have more severe TBIs than women
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Sam: That doesn't surprise me.
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Dana: So there is a difference in
the gender distribution as well.
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Sam: Perfect.
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And I noticed in the article you
did a review of the literature
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from the last 20 years.
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Has there been a lot published
on the topic in that timeframe?
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Dana: Yes.
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So there was a lot of literature
that we combed through.
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We looked for the most comprehensive
literature that would actually help
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people really understand the mechanisms
behind TBIs and how to treat TBIs
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because some of the literature was
unfortunately not very conclusive.
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And so we were looking for more
of the conclusive literature,
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like I said, how to treat it.
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The most pertinent imaging
when to go for surgery.
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So thankfully, especially the
more recent literature, has been
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great about that . So we had a lot
of good resources to work with.
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Sam: Excellent.
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And in the pathophysiology section,
there is a distinction drawn
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between primary and secondary TBI.
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Tell me more about that.
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And how that fits into
our clinical practice.
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Dana: Yeah.
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So primary TBI is.
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a direct injury and the secondary brain
injury is the sequela of that initial TBI.
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So, with primary TBIs, it can
be an open or a closed injury.
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So, you know, either smash your
head against something or you.
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In another way, you can get stabbed or
a gunshot wound and things like that.
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So there's lots of different ways that
a primary TBI can happen . And then
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the secondary brain injury that happens
is, like I said, the sequela of it.
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So increased pressure in your brain,
decreased oxygenation to your brain,
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decreased blood flow to your brain and
then the process behind that cell injury.
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So the Wallerian degeneration.
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That occurs, the glutamate release
that occurs which really damages
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those structures in the brain.
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So that's why there's a
distinction between primary
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and secondary brain injury.
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Sam: Gotcha.
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And then there is also a discussion
of the various types of hemorrhage
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and hematomas that can occur.
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None of that though, has changed as far as
definitions in the last couple of decades.
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What we know as subarachnoid
hemorrhage, epidurals, and subdurals
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is still the standard definition.
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Dana: Yes, they're still the same.
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Sam: Excellent.
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And the epidemiology section.
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This is the part that always fascinates
me the most, but you already mentioned the
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number of patients per year in the US and,
the male predilection versus the females.
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But, I did find it interesting that there
are like almost 50,000 deaths each year
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attributed to isolated traumatic brain
injury, which is a pretty high number
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of people with significant injuries.
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and half of those deaths occur just
in the first few hours after injury.
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And then there's a pretty
significant population of them
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occurring in children as well.
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Dana: Yeah.
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So there are several factors.
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So it depends of course, on
the mechanism of the injury.
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Some injuries are just irreversible,
catastrophic injuries, and that's
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why they die in the first few hours.
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And then it also depends on
what resources you even have.
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You know what hospital you
go to and things like that.
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Some hospitals are incredibly specialized
at treating these traumatic brain
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injuries, but unfortunately, in more
remote areas, the closest hospital or any
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hospital in the area just may not be as
well equipped to handle these severe TBIs.
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So , the treatments that a person
receives will also affect it.
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And unfortunately.
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Yes, children also do develop these
severe TBIs, and that can be from
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injury from either accidental injury or
injury from others and things like that.
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So those do unfortunately also happen.
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And there's even less literature
on how to treat children with TBIs.
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So, we know less unfortunately on what
numbers to aim for intracranial monitoring
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and all those things for children.
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Sam: Gotcha.
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And I saw in the issue there's a
table, table one, which kind of
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discusses the most common etiologies
for traumatic brain injury, putting
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fall at the top of that list.
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for all populations, all ages and
then direct trauma and motor vehicle
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collisions being the third most common.
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There is a distinction now
between mild and the moderate to
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severe traumatic brain injuries.
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Tell me about that classification.
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Dana: Yeah.
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So between a mild, moderate, and severe,
it really depends on the duration of loss
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of consciousness and duration of amnesia.
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So with moderate and severe,
there's a loss of consciousness
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that's, a greater than 24 hours.
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And your GCS score is much lower on the
spectrum as opposed to mild TBI where
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your loss of consciousness is very brief.
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It's like 30 minutes . amnesia
is also less than 24 hours.
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So you're transiently altered, but you
essentially get back to your baseline.
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But with moderate and severe TBI you do
not get back to your baseline essentially.
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Sam: gotcha.
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It, it's funny 'cause I actually
wouldn't consider that to be mild in
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general practice if somebody said they
were actually out for 25 minutes or so.
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But 30 minutes is the general
accepted guideline there.
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Dana: Exactly.
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Sam: Okay.
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Good to know.
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And then there is also in the
classification, a distinction
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between impact versus
Non-contact or inertial loading.
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which is actually not terminology
I'm accustomed to using in
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the emergency department.
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Tell me more about that.
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Dana: Yeah.
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So, the way I can kind of describe it,
it might not be the best, honestly.
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But the way I can describe it is that,
like you said, there's two kinds.
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So there's impact loading
and also inertial loading.
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So impact loading it produces more focal
injuries like local skull fractures,
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epidural hematomas and inertial loading
is more of a diffuse injury of the brain.
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So.
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Concussions are more of a diffuse injury.
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Subdurals can be very large and
encompass essentially the outer portion
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of the entire half of the hemisphere.
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So that's what the difference is.
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And diffuse axonal injury, which
is a secondary brain injury.
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So , the difference is more focal
versus more of a diffuse injury.
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Sam: Gotcha.
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And then when we talk about.
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All things on this podcast.
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We always mention the differential
diagnosis, but really this is quite broad.
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It's just a differential diagnosis
for altered mental status.
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So anything from intoxication
to dehydration, to infection,
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anything you can think of that might
cause altered mentation even, you
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know, hypoglycemia for example.
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All of that is on the list.
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As far as the differential is concerned.
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For our colleagues who are listening
who work in the pre-hospital arena
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is there anything new or maybe
even just critically important that
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we would encourage them to do as
pre-hospital providers in EMS agencies?
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Dana: As you mentioned, it's a very
broad differential for these patients,
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so I would just keep an open mind
when you're working these patients up
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as to, other concurrent issues that
might be going on along with the TBI
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because it's very easy and I'm sure it
happens very often, that people think,
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oh, this person has a TBI, they were
in insert blank, you know, accident.
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We are going to treat them for that.
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But it's also very important to
correct other metabolic etiologies,
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other electrolyte abnormalities,
arrhythmias ensure that you're not
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missing any seizures, for example.
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Because a lot of other concurrent
issues could have also caused this.
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And if they're missed, it could, you know,
prove to be pretty catastrophic later.
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So having a very low threshold , for
doing a broad workup for why the TBI
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happen is essentially as important
almost as treating the TBI itself.
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Sam: Good to know.
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And if they are on scene and our medics
are there , the initial GCS is a critical
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piece of information to gather and report
along with their initial vitals and,
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you know, making sure that information
is relayed to our emergency providers.
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I noticed that you mentioned,
blood pressure, oxygen measures
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taken, especially in the field.
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that there is a lot of debate
always about stabilizing patients
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on scene, how much time you take on
scene versus, you know, how quickly
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you can get them to a hospital.
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Is there anything new in that
arena as far as evidence goes?
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Or, did you find anything
helpful as far as data goes?
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Dana: Yeah, so there have been
multiple studies that I've looked
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at this, . There's for example, the
Epic study which was the excellence
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in pre-hospital injury care study.
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So , in this study, they included
over 21 patients with TBIs.
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And they were separated
by different categories.
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And then what they looked at was, you
know, pre-hospital outcomes along TBI
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categories , as I said, and there was
greatest benefit among stabilizing
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these patients if they had severe TBIs.
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There was also the OPALS study,
which was done in Canada.
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So this was the Ontario Pre-Hospital
Advanced Life support study.
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And it compared outcomes
with life support.
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Either the patient got life support
measures on the field, including
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intubation, so pre-hospital care versus
while they got to the hospital and there
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was really no decrease in mortality after
they implemented the pre-hospital care.
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00:12:18,984 --> 00:12:22,624
But this is certainly an area
that's not black and white.
234
00:12:22,894 --> 00:12:25,424
It really depends on the entire situation.
235
00:12:25,424 --> 00:12:29,654
So how your EMS crew is able
to stabilize the patient.
236
00:12:29,834 --> 00:12:33,704
How far away are you from the
facility, what kind of injury
237
00:12:33,704 --> 00:12:35,614
the patient has et cetera.
238
00:12:35,614 --> 00:12:38,036
So there are multiple factors
that always go into this.
239
00:12:38,036 --> 00:12:42,596
So there is not still a clear cut
answer from the literature that we saw
240
00:12:42,596 --> 00:12:45,778
about stabilizing the patient before
they make it to the hospital versus
241
00:12:45,918 --> 00:12:46,868
when they come into the hospital.
242
00:12:47,668 --> 00:12:50,698
Sam: Yeah, this always seems to be
a discussion for us, depending on
243
00:12:50,698 --> 00:12:54,598
the community that the agency is
kind of nestled in, whether it's
244
00:12:54,598 --> 00:12:58,268
rural or if they have access to a
trauma center and if their transport
245
00:12:58,268 --> 00:12:59,888
times are very short or long.
246
00:13:00,202 --> 00:13:04,612
So Certainly there are excellent
medics out there with great skills
247
00:13:04,612 --> 00:13:06,292
who are able to intubate in the field.
248
00:13:06,342 --> 00:13:11,072
And the debate really isn't about their
skill, it's more about just the ultimate
249
00:13:11,072 --> 00:13:14,912
patient outcome and whether or not they
can get to a trauma center quickly.
250
00:13:15,282 --> 00:13:16,422
.
And what's most beneficial.
251
00:13:16,422 --> 00:13:20,122
So, good to see that there's
still evolving data in that field.
252
00:13:20,122 --> 00:13:24,347
It sounds like it's a very heterogeneous
mix of agencies and patients.
253
00:13:24,347 --> 00:13:28,257
So, it'll be interesting to see
over the next decade if anything
254
00:13:28,257 --> 00:13:29,757
different ends up being recommended.
255
00:13:30,237 --> 00:13:35,467
When they get to the emergency department
and we're evaluating them and we're just
256
00:13:35,467 --> 00:13:41,017
talking about history, are there any
specific elements that are most helpful to
257
00:13:41,017 --> 00:13:42,502
pull out in the history with the patient?
258
00:13:43,302 --> 00:13:45,702
Dana: Yeah, so there's a lot
of information if you are able
259
00:13:45,702 --> 00:13:46,992
to get it from the patient.
260
00:13:47,352 --> 00:13:50,112
So how did this injury happen?
261
00:13:50,232 --> 00:13:51,792
When did this injury happen?
262
00:13:52,032 --> 00:13:53,982
What medications do you take?
263
00:13:53,982 --> 00:13:56,592
Do you have any prior medical history?
264
00:13:56,922 --> 00:14:00,032
Like, do you have a record of
this injury even happening?
265
00:14:00,342 --> 00:14:03,952
So those are just the basic questions
that you really wanna ask them
266
00:14:03,952 --> 00:14:05,548
before you start examining them.
267
00:14:05,738 --> 00:14:09,093
'Cause it's especially important when I
mention medications like, are there on any
268
00:14:09,893 --> 00:14:14,033
antiplatelet agents or any anticoagulants
because those, you have to reverse.
269
00:14:14,283 --> 00:14:18,123
Unless there's a contraindication, those
need to be reversed, especially if they
270
00:14:18,123 --> 00:14:22,893
have an intracranial bleed because that
bleed can worsen very quickly, otherwise.
271
00:14:23,188 --> 00:14:23,608
Sam: Gotcha.
272
00:14:24,408 --> 00:14:29,788
And then in the physical examination
portion we mentioned getting a GCS is
273
00:14:29,788 --> 00:14:34,318
very important in the field, but then
also important to repeat multiple times.
274
00:14:34,318 --> 00:14:38,188
So we're gonna repeat it again in the ED
when we go to do our physical examination.
275
00:14:38,728 --> 00:14:39,058
Dana: Yeah.
276
00:14:39,328 --> 00:14:39,748
Yes.
277
00:14:39,908 --> 00:14:44,038
So the GCS is a nice pretty quick way
of just assessing the progression of
278
00:14:44,038 --> 00:14:45,928
your patient and their physical exam.
279
00:14:46,258 --> 00:14:49,408
And especially their pupils, if they're
talking, if they're still moving their
280
00:14:49,408 --> 00:14:52,608
extremities, or if something has acutely
changed, which means that intracranially,
281
00:14:53,428 --> 00:14:55,978
something may have also acutely changed.
282
00:14:55,978 --> 00:15:00,348
So it's a nice, fast way to
continuously assess the patient.
283
00:15:01,148 --> 00:15:01,508
Sam: Gotcha.
284
00:15:01,598 --> 00:15:06,998
So GCS pupils your basic neuro
exam, and then also dealing with the
285
00:15:06,998 --> 00:15:10,268
rest of the injuries that accompany
their traumatic brain injury.
286
00:15:10,688 --> 00:15:11,348
Dana: Exactly.
287
00:15:11,748 --> 00:15:13,398
Sam: And then diagnostics.
288
00:15:13,488 --> 00:15:18,418
All of these patients are going to get a
CT scan and when they get their CT, you
289
00:15:18,418 --> 00:15:21,898
know, hopefully we have a radiologist
there to provide a rapid interpretation.
290
00:15:21,898 --> 00:15:26,518
But if not, there is an interesting
schema for interpreting or making
291
00:15:26,518 --> 00:15:30,283
sure you don't miss things on
non-contrast CTs of the brain.
292
00:15:30,383 --> 00:15:36,023
In table six, the, the A-B-B-B-C approach
which I had never seen before, but seems
293
00:15:36,023 --> 00:15:37,793
to be a very well articulated approach.
294
00:15:37,793 --> 00:15:38,663
Tell me more about that.
295
00:15:39,353 --> 00:15:44,238
Dana: Yeah, so as a neurologist, I kind of
take it for granted how at this point, how
296
00:15:44,268 --> 00:15:46,728
pretty easy it is to interpret CAT scans.
297
00:15:46,968 --> 00:15:49,128
But of course not everyone
comes with that skill.
298
00:15:49,128 --> 00:15:52,008
We all do different residencies,
we all have different strengths.
299
00:15:52,278 --> 00:15:57,858
So as we were interpreting the literature,
I found this table from this resource and
300
00:15:57,858 --> 00:16:00,888
I thought it was really excellent to add
because it in a really straightforward
301
00:16:00,888 --> 00:16:04,998
way, really explained the different
major and very important components
302
00:16:04,998 --> 00:16:06,708
of what to look for on a CAT scan.
303
00:16:07,068 --> 00:16:07,518
So.
304
00:16:08,108 --> 00:16:09,248
For example, air.
305
00:16:09,298 --> 00:16:13,048
Of course we do have air in our
sinuses, but there should not be air
306
00:16:13,108 --> 00:16:16,978
within our cranial vaults or anywhere
else, like really intracranially and
307
00:16:16,978 --> 00:16:18,658
that's associated with a fracture.
308
00:16:19,018 --> 00:16:19,558
Bones.
309
00:16:19,558 --> 00:16:23,248
So looking at the bone windows is
very important to make sure also
310
00:16:23,248 --> 00:16:25,138
that there's no fractures anywhere.
311
00:16:25,438 --> 00:16:26,128
Blood is.
312
00:16:26,608 --> 00:16:30,058
Decently it, it's pretty easy
to pick up on the CAT scan.
313
00:16:30,338 --> 00:16:33,848
And this kind of explained the way
that subarachnoid hemorrhages that are
314
00:16:33,848 --> 00:16:36,348
traumatic would look on the CAT scan.
315
00:16:36,348 --> 00:16:39,988
And same thing with subdurals and
how they're crescent shaped versus
316
00:16:39,988 --> 00:16:42,058
epidurals, which are lens shaped.
317
00:16:42,208 --> 00:16:46,558
So that really distinguishes the two there
and also what intraparenchymal hemorrhages
318
00:16:46,558 --> 00:16:50,751
look like, which is quite bright white,
but not as white as the bone itself
319
00:16:51,471 --> 00:16:54,543
.
And also it explains , in the brain
itself, how to see the differentiation
320
00:16:54,543 --> 00:16:56,193
between the gray and the white matter.
321
00:16:56,553 --> 00:17:00,613
And also the CSF spaces as well and
how they look like, what the four
322
00:17:00,613 --> 00:17:04,513
structures look like, and if there
is a concern for hydrocephalus.
323
00:17:04,843 --> 00:17:05,803
What you may see.
324
00:17:05,803 --> 00:17:09,533
So you would see effacement in
the sulci, the cisterns and the
325
00:17:09,533 --> 00:17:11,153
ventricles themselves would be larger.
326
00:17:11,153 --> 00:17:15,137
So I thought this was a really nice
table to kind of separate and explain the
327
00:17:15,137 --> 00:17:17,367
different components of a basic CAT scan
328
00:17:18,240 --> 00:17:18,530
.
Sam: Yeah.
329
00:17:18,925 --> 00:17:19,105
Yeah.
330
00:17:19,110 --> 00:17:22,025
It's a, great little resource to
keep in your back pocket if you're
331
00:17:22,025 --> 00:17:23,735
not accustomed to looking at CTs.
332
00:17:24,135 --> 00:17:28,955
And then when it comes to the timing
of repeating that CT scan are there
333
00:17:28,955 --> 00:17:32,825
guidelines for what is the ideal time
or is it just when their exam changes?
334
00:17:33,625 --> 00:17:37,215
Dana: So when we were doing our literature
review, this is not something that we
335
00:17:37,275 --> 00:17:40,598
like personally practiced, but very
few of the guidelines recommended up
336
00:17:40,598 --> 00:17:43,118
to 24 hours from the first CAT scan.
337
00:17:43,918 --> 00:17:47,728
Everyone that I have worked with, and
the majority of the literature has really
338
00:17:47,728 --> 00:17:52,078
supported repeating a CAT scan in about
four to six hours from the initial one.
339
00:17:52,348 --> 00:17:56,788
Or if there's an exam change that you
do want to emergently repeat a CAT scan
340
00:17:56,818 --> 00:17:59,141
before that four to six hour window.
341
00:17:59,711 --> 00:18:00,101
Sam: Gotcha.
342
00:18:00,101 --> 00:18:05,351
So this is if they're presenting with a
moderate to severe brain injury and they
343
00:18:05,351 --> 00:18:07,241
have an abnormality on the initial scan.
344
00:18:07,901 --> 00:18:11,351
Then you go for a, a repeat
at some set timeframe.
345
00:18:11,861 --> 00:18:12,431
Dana: Exactly.
346
00:18:12,611 --> 00:18:16,751
And even if they may not have initially
an abnormality on their CAT scan, but
347
00:18:16,751 --> 00:18:21,491
you know that they had a severe TBI and
if they have an exam change, you would
348
00:18:21,491 --> 00:18:25,241
still repeat the CAT scan because they
may have developed a new abnormality.
349
00:18:25,521 --> 00:18:27,950
Sometimes the blood in the
traumatic brain injury patient
350
00:18:27,950 --> 00:18:29,660
can actually blossom intracranial.
351
00:18:30,090 --> 00:18:31,710
And that does not happen right away.
352
00:18:31,830 --> 00:18:35,090
So that's just one example where
you really need to keep a really
353
00:18:35,090 --> 00:18:38,570
close eye, do very frequent
neurologic checks on these patients.
354
00:18:38,850 --> 00:18:41,940
And if anything changes, have a
very low threshold to repeat the
355
00:18:41,940 --> 00:18:43,440
CAT scan to see what's going on.
356
00:18:43,950 --> 00:18:44,280
Sam: Gotcha.
357
00:18:44,680 --> 00:18:48,814
And I was happy to see a discussion
here about the use of bedside ultrasound
358
00:18:48,924 --> 00:18:50,575
for optic nerve sheath diameter.
359
00:18:50,575 --> 00:18:53,440
You know, we're always looking
for things to use our ultrasound
360
00:18:53,440 --> 00:18:56,805
for in the ED, so there is a
role for this in this population.
361
00:18:57,605 --> 00:18:57,965
Dana: Yes.
362
00:18:58,085 --> 00:19:01,795
So if you don't have any kind of
intracranial monitor, so an EVD
363
00:19:01,795 --> 00:19:05,045
or a bolt or anything like that
optic nerve sheath diameter is
364
00:19:05,045 --> 00:19:06,995
really your window into the brain.
365
00:19:07,085 --> 00:19:11,535
Otherwise the optic nerve is an
extension into the central nerve system.
366
00:19:11,865 --> 00:19:14,475
But the important thing with
optic nerve sheath diameter
367
00:19:14,475 --> 00:19:16,245
is that you need to trend it.
368
00:19:16,525 --> 00:19:20,175
Doing just one measurement It
won't really help you truthfully.
369
00:19:20,589 --> 00:19:25,419
So this is something that we generally try
to do at least once or twice per shift and
370
00:19:25,419 --> 00:19:28,119
see if that number gets bigger, bigger.
371
00:19:28,339 --> 00:19:31,729
So I think I actually, somewhere
I included an example of what the
372
00:19:31,729 --> 00:19:32,839
optic nerve sheath looks like.
373
00:19:32,839 --> 00:19:36,663
So about 0.5 was normal, and
then we can see that later became
374
00:19:36,733 --> 00:19:39,149
abnormal and went to point seven.
375
00:19:39,449 --> 00:19:44,669
So if that does increase, then that's
an indication for the providers
376
00:19:44,669 --> 00:19:48,029
that the patient may be developing
higher intracranial pressures.
377
00:19:48,389 --> 00:19:48,779
Sam: Gotcha.
378
00:19:49,079 --> 00:19:51,579
And now there's two different
measurements that can be obtained.
379
00:19:51,639 --> 00:19:55,299
One is the optic nerve, sheath
diameter, and the other is the actual
380
00:19:55,389 --> 00:19:57,549
elevation of the optic disc as well.
381
00:19:57,549 --> 00:19:59,229
You can see both of those on ultrasound.
382
00:19:59,854 --> 00:20:02,074
Dana: Yes, both of those
can be seen on ultrasound.
383
00:20:02,284 --> 00:20:02,644
Sam: Gotcha.
384
00:20:03,134 --> 00:20:08,294
And when you're doing this measurement,
you are doing it with the patient's head
385
00:20:08,294 --> 00:20:10,244
of bed, still elevated at 30 degrees.
386
00:20:10,889 --> 00:20:11,399
Dana: Yes.
387
00:20:11,459 --> 00:20:14,279
So it's important also for
consistency to have the patient's
388
00:20:14,279 --> 00:20:16,289
head of bed at 30 degrees for this.
389
00:20:16,549 --> 00:20:20,269
Just because if you lay a patient flat,
their intracranial pressure can of course
390
00:20:20,359 --> 00:20:21,829
be higher than when they're sitting up.
391
00:20:21,829 --> 00:20:25,689
So, consistency is key when you're
doing all of these measurements.
392
00:20:25,869 --> 00:20:26,229
Sam: Gotcha.
393
00:20:26,619 --> 00:20:31,299
And if you are giving something for
increased intracranial pressure, would
394
00:20:31,299 --> 00:20:36,709
you expect to see this optic nerve
sheath diameter change in real time.
395
00:20:37,119 --> 00:20:40,659
Dana: If you're able to do those
things simultaneously, I anticipate
396
00:20:40,659 --> 00:20:44,049
that you would be able to see a
decrease in intracranial pressure
397
00:20:44,049 --> 00:20:45,429
with the optic nerve sheath diameter.
398
00:20:45,429 --> 00:20:49,459
Yeah, it's essentially a live measurement
as you would see with, you know,
399
00:20:49,459 --> 00:20:51,319
like I said, like an EVD or a bolt.
400
00:20:51,709 --> 00:20:51,839
Sam: That's cool.
401
00:20:52,459 --> 00:20:52,969
That's very cool.
402
00:20:52,969 --> 00:20:53,959
All right.
403
00:20:53,999 --> 00:20:58,244
And then there was a discussion about
pupillometry, which is actually, again,
404
00:20:58,244 --> 00:21:01,754
not something I'm accustomed to doing,
but, but seems like it should be.
405
00:21:01,914 --> 00:21:04,734
Tell me about what that is and
what evidence we have for that.
406
00:21:05,534 --> 00:21:08,444
Dana: Yeah, so pupilometers
are some of our best.
407
00:21:08,744 --> 00:21:12,954
We love our pupilometers, especially
in the neuro ICU just because with a
408
00:21:12,954 --> 00:21:18,029
pen light, sometimes it can be a little
challenging to consistently especially
409
00:21:18,029 --> 00:21:21,269
between providers and things like that,
to really assess what the pupillary
410
00:21:21,569 --> 00:21:24,539
reactivity is what the size is, et cetera.
411
00:21:24,689 --> 00:21:28,679
So what a pupilometer does, it's
a non-invasive, again, technique
412
00:21:28,989 --> 00:21:32,619
when it assesses the pupil size
symmetry and the light reflex.
413
00:21:32,839 --> 00:21:36,749
So it gives you essentially
an NPI number, which.
414
00:21:37,464 --> 00:21:40,224
It gives you the size of the pupil
and it also gives you the percent
415
00:21:40,224 --> 00:21:44,693
change of the pupil which you
can't get with a regular pen light.
416
00:21:44,903 --> 00:21:49,283
So that's why we prefer using a
pupilometer over just using a pen light.
417
00:21:49,463 --> 00:21:52,592
If you have nothing else, of course
a pen light is acceptable . But
418
00:21:52,592 --> 00:21:54,182
if the pupilometer is available,
419
00:21:54,237 --> 00:21:54,637
that's
420
00:21:54,637 --> 00:21:57,837
something that we would
highly prefer that's used.
421
00:21:58,237 --> 00:22:02,177
Sam: And is the pupilometer that you
use, is it , a separate device or is this
422
00:22:02,177 --> 00:22:03,987
an app on your phone that you can use?
423
00:22:04,702 --> 00:22:08,406
Dana: It's a separate device, so it's
not too big and you just hold it in your
424
00:22:08,406 --> 00:22:10,626
hand and you hold it to the patient's eye.
425
00:22:10,956 --> 00:22:15,306
And then we shut the lights off and
then it measures the pupillary size.
426
00:22:15,306 --> 00:22:18,966
So you just keep it on the patient's
face for just a few seconds and then it
427
00:22:19,056 --> 00:22:21,676
gives you all of those numbers on the
screen that comes with the pupilometer.
428
00:22:22,686 --> 00:22:23,256
Sam: That's great.
429
00:22:23,286 --> 00:22:24,276
And you're doing both eyes?
430
00:22:24,606 --> 00:22:25,056
Dana: Yes.
431
00:22:25,266 --> 00:22:26,526
Sam: Okay, excellent.
432
00:22:27,226 --> 00:22:30,706
And just out of curiosity, does it dump
that information into the electronic
433
00:22:30,706 --> 00:22:33,466
health record, or do you just go back
and copy that down into your note?
434
00:22:34,266 --> 00:22:38,311
Dana: So, as far as I know we use
Epic throughout our system, but the
435
00:22:38,321 --> 00:22:40,721
pupilometer does not connect to Epic.
436
00:22:41,001 --> 00:22:45,501
So the nurses do have to input it every
time they do it, and then we see their
437
00:22:45,531 --> 00:22:47,331
numbers and trends and things like that.
438
00:22:47,331 --> 00:22:50,674
And we repeat it at bedside
ourselves when we assess patients.
439
00:22:50,924 --> 00:22:53,204
So those numbers go
into our notes as well.
440
00:22:53,504 --> 00:22:55,694
So that information is also
carried on in multiple ways.
441
00:22:56,494 --> 00:23:01,624
Sam: And you're looking for trends
as in worsening pupillary reflexes
442
00:23:01,654 --> 00:23:05,059
being a surrogate marker for worsening
brain injury or brain function.
443
00:23:05,859 --> 00:23:06,549
Dana: Exactly.
444
00:23:06,739 --> 00:23:10,399
So with the percent change and with
the size of the pupil, those are
445
00:23:10,739 --> 00:23:14,749
really two of the things that we
look at, and also pupilary asymmetry.
446
00:23:14,749 --> 00:23:20,819
So if the pupilary size starts to decrease
or increase, if the percent change
447
00:23:20,819 --> 00:23:26,759
starts to decrease, then those are really
alarms for us that something intracranial
448
00:23:26,759 --> 00:23:31,109
like either the bleed is expanding,
there's a new bleed, you know, something
449
00:23:31,229 --> 00:23:33,129
is acutely worse with the patient.
450
00:23:33,429 --> 00:23:33,759
Sam: Gotcha.
451
00:23:34,269 --> 00:23:34,989
That's pretty cool.
452
00:23:35,389 --> 00:23:38,029
And then there was a
discussion about biomarkers.
453
00:23:38,029 --> 00:23:41,839
So where are we today as far as
reliability of biomarkers , and
454
00:23:41,839 --> 00:23:44,079
how we would incorporate
them into clinical practice.
455
00:23:44,879 --> 00:23:49,409
Dana: So biomarkers are something
that can be used in conjunction with
456
00:23:49,409 --> 00:23:53,629
the data that we have, but there's
still a copious amount of research
457
00:23:53,629 --> 00:23:59,219
that's going on in the realm of TBI
as to how useful these biomarkers are.
458
00:23:59,439 --> 00:24:02,899
Just because, for example, so I'll
discuss like neuron specific amylase
459
00:24:02,919 --> 00:24:06,069
because that's something that's
been around for a very long time.
460
00:24:06,069 --> 00:24:09,099
And we also use it for our
cardiac arrest patients.
461
00:24:09,519 --> 00:24:14,619
The concentrations do rise in about
the first 12 hours after the injury.
462
00:24:14,929 --> 00:24:18,489
But the specificity, it can be kind
of limited because other factors
463
00:24:18,489 --> 00:24:22,849
can also affect the neuron specific
amylase level and can make it look
464
00:24:22,939 --> 00:24:24,709
high because there are other reasons.
465
00:24:24,709 --> 00:24:29,689
So if a person is undergoing
hemolysis, if they're on ECMO and also.
466
00:24:30,094 --> 00:24:33,584
Like , there are other factors that
can kind of affect the level that
467
00:24:33,584 --> 00:24:34,874
you get for neuron specifically?
468
00:24:34,874 --> 00:24:37,424
Some labs even process
the lab differently.
469
00:24:37,424 --> 00:24:41,624
So it's something that can be used in
conjunction with all of your other tests.
470
00:24:41,874 --> 00:24:48,084
But it's not something that we use yet
by itself to predict how a patient will
471
00:24:48,084 --> 00:24:50,484
do in their course with their severe TBI.
472
00:24:50,724 --> 00:24:51,144
Sam: Gotcha.
473
00:24:51,444 --> 00:24:54,547
Okay, let's move on to treatment.
474
00:24:54,547 --> 00:24:58,196
Once we've gotten our objective
data and we know that they have a
475
00:24:58,196 --> 00:25:01,316
traumatic brain injury, and maybe
we've gotten some abnormal imaging
476
00:25:01,536 --> 00:25:05,551
and we're moving on to treatment
when we start with airway management.
477
00:25:05,771 --> 00:25:11,471
It seems like our standard airway
protocols, including medications like
478
00:25:11,531 --> 00:25:15,691
etomidate and succinylcholine are, safe
to use and there's no reason to avoid
479
00:25:15,691 --> 00:25:17,071
these in this specific population.
480
00:25:17,871 --> 00:25:18,261
Dana: Yeah.
481
00:25:18,331 --> 00:25:22,581
So, both succinylcholine and rocuronium
are fine to use and etomidate is
482
00:25:22,581 --> 00:25:27,351
fine to use just the precautions with
succinylcholine that we know from even,
483
00:25:27,411 --> 00:25:29,451
you know, outside of our TBI population.
484
00:25:29,451 --> 00:25:33,811
So if someone is hyperkalemic or
they have a known neuromuscular
485
00:25:33,811 --> 00:25:36,991
disorder, then I would avoid
succinylcholine . But otherwise,
486
00:25:36,991 --> 00:25:38,821
both are absolutely fine to use.
487
00:25:39,041 --> 00:25:43,221
And there was a concern historically
about using ketamine with the concern
488
00:25:43,221 --> 00:25:46,621
of how it would affect the ICP but
it's not supported by evidence.
489
00:25:46,621 --> 00:25:49,121
So it is okay to use ketamine as well.
490
00:25:49,391 --> 00:25:49,871
Sam: Great.
491
00:25:50,511 --> 00:25:55,051
And then there has always been
historically the notion that you
492
00:25:55,051 --> 00:25:59,491
could always hyperventilate somebody
in an emergency to temporarily
493
00:25:59,491 --> 00:26:00,901
reduce intracranial pressure.
494
00:26:00,901 --> 00:26:06,861
But there are some good published studies
for where we want that measure to be and
495
00:26:06,861 --> 00:26:09,231
what we want that CO2 level to reach.
496
00:26:09,231 --> 00:26:10,461
Tell me more about that.
497
00:26:11,241 --> 00:26:13,990
Dana: Yeah, so the latest literature
really supports keeping the patient's
498
00:26:13,990 --> 00:26:19,944
CO2 at about 35 to 45, just because of
the long-term effects after the patient
499
00:26:19,944 --> 00:26:21,984
gets intubated more than anything else.
500
00:26:22,164 --> 00:26:25,934
So we really want to avoid, of course,
keeping them you know, hypoxic.
501
00:26:25,934 --> 00:26:27,794
We don't want them to be hypercarbic.
502
00:26:28,204 --> 00:26:30,674
Because of the fact that
it can cause, strokes.
503
00:26:30,954 --> 00:26:34,541
So that's why we really prefer
because of like the vasoconstrictive
504
00:26:34,541 --> 00:26:35,861
and vasodilatory effects.
505
00:26:35,861 --> 00:26:38,381
So long term we do not
wanna keep them hypo capic.
506
00:26:38,681 --> 00:26:42,641
So that's why we really, if
feasible, would prefer an aim of
507
00:26:42,641 --> 00:26:46,001
the PaCO2 to be about 35 to 45.
508
00:26:46,721 --> 00:26:47,231
Sam: Perfect.
509
00:26:47,471 --> 00:26:53,591
And the ideal therapy for
increased intracranial pressure.
510
00:26:53,591 --> 00:26:57,131
You've got a couple of options, or there
was a discussion in the article about
511
00:26:57,131 --> 00:26:59,681
hypertonic saline and about mannitol.
512
00:26:59,681 --> 00:27:03,461
So let's start with hypertonic
saline, if that's available to us.
513
00:27:03,561 --> 00:27:05,751
There's good evidence that
that works and it's safe to
514
00:27:05,751 --> 00:27:07,261
administer , and it works quickly.
515
00:27:08,061 --> 00:27:08,421
Dana: Yes.
516
00:27:08,546 --> 00:27:10,406
So hypertonic saline is great.
517
00:27:10,626 --> 00:27:15,396
It comes in different concentrations,
anywhere from 3% to 23%.
518
00:27:15,766 --> 00:27:20,416
The way that it works is that it decreases
the ICP by causing an osmotic shift of
519
00:27:20,416 --> 00:27:26,096
fluid from the intracellular space to the
interstitial and intravascular spaces.
520
00:27:26,456 --> 00:27:30,816
And this draws additional fluid in
and while it helps maintain mass by
521
00:27:30,816 --> 00:27:35,769
also lowering the ICP it's probably
more challenging in the ED to get 23%.
522
00:27:35,769 --> 00:27:41,359
So from what I saw in the literature
mostly 3%, two 50 CC bolus is used
523
00:27:41,599 --> 00:27:44,389
and the osmolarity for that is 1,026.
524
00:27:44,474 --> 00:27:45,764
Milli Osmoles.
525
00:27:45,954 --> 00:27:49,554
Hypertonic saline is far more
concentrated, of course, and
526
00:27:49,554 --> 00:27:50,754
it has a higher osmolarity.
527
00:27:50,754 --> 00:27:53,654
It's about 8,008 milli osmoles.
528
00:27:54,084 --> 00:27:56,934
There is also, and it's important
to know, is there's a difference
529
00:27:56,934 --> 00:28:01,602
with how this is administered . So
hypertonic saline, that's 23%
530
00:28:01,602 --> 00:28:03,117
is given through a central line.
531
00:28:03,312 --> 00:28:04,542
Over about 10 minutes.
532
00:28:04,732 --> 00:28:08,212
But two 50 ccs of 3% can be
given through a peripheral iv.
533
00:28:08,922 --> 00:28:12,762
But they both help with that temporizing
measure of decreasing the intracranial
534
00:28:12,762 --> 00:28:15,789
pressure, especially as you're
initially stabilizing the patient.
535
00:28:16,389 --> 00:28:16,809
Sam: Gotcha.
536
00:28:16,989 --> 00:28:23,039
And if we're giving the 3%, 250
cc quantity of hypertonic saline,
537
00:28:23,339 --> 00:28:26,519
, that's not a push bolus that's
going in over 20 minutes or so.
538
00:28:26,759 --> 00:28:27,209
Dana: Correct.
539
00:28:27,209 --> 00:28:28,229
Over 20 minutes.
540
00:28:28,259 --> 00:28:29,339
Sam: Okay, great.
541
00:28:29,899 --> 00:28:33,629
And if for some reason we have
mannitol and don't have hypertonic
542
00:28:33,629 --> 00:28:35,609
saline, is it okay to use mannitol?
543
00:28:35,609 --> 00:28:37,529
Does that also have a, beneficial effect?
544
00:28:38,279 --> 00:28:40,709
Dana: Yes, mannitol is
also really great to use.
545
00:28:40,919 --> 00:28:45,079
The major caveat with mannitol is
we do not use it with our end stage
546
00:28:45,079 --> 00:28:49,169
renal disease patients if they're
on dialysis because it can cause
547
00:28:49,169 --> 00:28:53,519
the opposite effects where it can
actually cause worsened cerebral edema.
548
00:28:53,799 --> 00:28:55,839
But mannitol is also very good.
549
00:28:55,899 --> 00:28:58,779
It works through a similar
but different mechanism.
550
00:28:59,059 --> 00:29:02,089
So it still does create
that osmotic gradient.
551
00:29:03,009 --> 00:29:05,259
It like the brain tissue
volume has decreased.
552
00:29:05,469 --> 00:29:06,969
It can decrease CPP.
553
00:29:07,329 --> 00:29:10,339
So it's also a very
useful medication to use.
554
00:29:10,589 --> 00:29:15,959
The labs that we frequently monitor
with mannitol, so we do check the serum
555
00:29:15,959 --> 00:29:18,809
osmolality if it is greater than three 20.
556
00:29:19,149 --> 00:29:22,089
And if, especially if the osmolar
gap is greater than 20, then
557
00:29:22,089 --> 00:29:24,349
we do tend to avoid using it.
558
00:29:24,589 --> 00:29:28,009
But otherwise, if a patient doesn't
have those issues and if they're not
559
00:29:28,009 --> 00:29:31,819
an end stage renal disease patient,
then it's fine to use manitol.
560
00:29:32,299 --> 00:29:32,689
Sam: Gotcha.
561
00:29:33,259 --> 00:29:37,489
And both hypertonic, saline and
mannitol have a pretty rapid onset.
562
00:29:38,289 --> 00:29:38,649
Dana: Yeah.
563
00:29:38,649 --> 00:29:44,606
So, within 10 to 20 minutes, mostly
we do see, and even at the, just
564
00:29:44,606 --> 00:29:48,086
anecdotally at the bedside, we do
see even faster responses in that,
565
00:29:48,086 --> 00:29:51,506
but typically it's, especially with
mannitol, about 10 to 20 minutes.
566
00:29:52,016 --> 00:29:52,706
Sam: Fantastic.
567
00:29:53,106 --> 00:29:57,486
And then we do all of this with
the goal of maintaining an ideal
568
00:29:57,516 --> 00:29:59,976
cerebral perfusion pressure.
569
00:29:59,976 --> 00:30:00,966
Tell me more about that.
570
00:30:01,766 --> 00:30:01,880
Dana: Yeah.
571
00:30:01,970 --> 00:30:04,702
So there's A compliant brains
and noncompliant brains.
572
00:30:04,702 --> 00:30:07,838
So compliant brains are far
more injured and they're not
573
00:30:07,838 --> 00:30:09,668
able to self auto-regulate.
574
00:30:09,908 --> 00:30:16,088
But with a compliant brain, you want
your CPP to be about 60 to 70 millimeters
575
00:30:16,088 --> 00:30:21,309
of mercury while keeping the ICP
less than 22 millimeters of mercury.
576
00:30:21,629 --> 00:30:24,689
So all of this is especially helpful
if we already, of course, have
577
00:30:24,689 --> 00:30:28,304
an intracranial device such as an
EVD because that can tell us what
578
00:30:28,304 --> 00:30:29,624
the ICP is and all those things.
579
00:30:29,624 --> 00:30:32,114
So we can easily calculate what that is.
580
00:30:32,114 --> 00:30:36,164
But those are the goals that we aim
for when we're managing these patients.
581
00:30:36,584 --> 00:30:36,824
Sam: Gotcha.
582
00:30:37,274 --> 00:30:40,124
And that cerebral perfusion
pressure is calculated how?
583
00:30:40,924 --> 00:30:44,394
Dana: So CPP is, it's the
cardinal formula in the neuro ICU.
584
00:30:44,394 --> 00:30:47,704
CPP equals map minus your ICP.
585
00:30:48,164 --> 00:30:51,771
So that's how you would get your
numbers where you have your patient's
586
00:30:51,771 --> 00:30:55,246
MAP, of course, and their ICP, and
then you would get the CPP from that.
587
00:30:55,881 --> 00:30:56,271
Sam: Gotcha.
588
00:30:56,571 --> 00:31:01,071
And even with an ideal cerebral
perfusion pressure, we still wanna
589
00:31:01,071 --> 00:31:06,491
keep their systolic above a hundred
just general guidelines for, recovery.
590
00:31:06,551 --> 00:31:06,941
Is that right?
591
00:31:07,661 --> 00:31:08,081
Dana: Yes.
592
00:31:08,181 --> 00:31:09,261
So it depends a little.
593
00:31:09,551 --> 00:31:13,661
In the Brain Trauma Foundation guidelines
it depends just a tiny bit on what their
594
00:31:13,661 --> 00:31:16,611
age is for the majority of patients.
595
00:31:16,681 --> 00:31:21,131
So for those that are 50 to 69 years
old it's greater than a hundred and
596
00:31:21,131 --> 00:31:27,701
then it's greater than 110 for the 15
to 49 and over 70-year-old patients.
597
00:31:28,121 --> 00:31:29,621
So just a slight variance.
598
00:31:29,741 --> 00:31:30,041
Sam: Gotcha.
599
00:31:30,441 --> 00:31:32,331
And then temperature management.
600
00:31:32,331 --> 00:31:35,181
We're looking for normothermia
in these patients.
601
00:31:35,981 --> 00:31:36,371
Dana: Yes.
602
00:31:36,561 --> 00:31:41,251
So one of the things that virtually
everyone agrees on is that higher
603
00:31:41,251 --> 00:31:44,851
temperatures increase cerebral
metabolic demand, and they worsen
604
00:31:44,851 --> 00:31:47,911
their risk for a lot of different
things such as cerebral ischemia.
605
00:31:48,221 --> 00:31:53,131
So that's why we prefer to keep
the brain always normothermic
606
00:31:53,961 --> 00:31:58,161
avoid fevers and also prophylactic
hypothermia is not recommended.
607
00:31:58,791 --> 00:31:59,121
Sam: Great.
608
00:31:59,521 --> 00:32:03,794
And then is it common to see
coagulopathies in this population?
609
00:32:03,824 --> 00:32:07,214
Is that as a result of medications
they're on or as a result of injury
610
00:32:07,214 --> 00:32:09,004
mechanisms or, or how, common is that?
611
00:32:09,404 --> 00:32:12,374
Dana: In the literature we
saw it varied extensively.
612
00:32:12,564 --> 00:32:16,474
It was between, I think I put
in the chapters between like 7%
613
00:32:16,474 --> 00:32:18,364
to like 60 something percent.
614
00:32:18,594 --> 00:32:20,874
And this can vary for a
lot of different reasons.
615
00:32:20,874 --> 00:32:24,714
So the patients could be on medications
that make them coagulopathic.
616
00:32:24,714 --> 00:32:27,984
They can have disease processes,
for example, like liver
617
00:32:27,984 --> 00:32:30,084
disorders, cancer, et cetera.
618
00:32:30,274 --> 00:32:33,364
That can also lead to
coagulopathic derangement.
619
00:32:33,364 --> 00:32:37,564
So that's why, as we had discussed
earlier, getting that initial
620
00:32:37,564 --> 00:32:41,944
history if able is very important
, especially if they have any kind of
621
00:32:41,974 --> 00:32:45,424
coagulopathic issues to see how it can
be reversed or managed appropriately.
622
00:32:46,224 --> 00:32:46,704
Sam: Gotcha.
623
00:32:46,914 --> 00:32:49,374
And that comes with a
significant mortality here.
624
00:32:49,374 --> 00:32:53,994
I saw that you guys cited a ninefold,
increased risk of mortality and a 30
625
00:32:53,994 --> 00:32:57,684
fold increased risk of unfavorable
outcome if they develop a coagulopathy.
626
00:32:58,374 --> 00:32:58,764
Dana: Yes.
627
00:32:58,764 --> 00:33:02,934
So it, of course, it depends on
how easily it can be reversed, how
628
00:33:03,114 --> 00:33:07,074
difficult or easy it is to treat
what the initial pathology is.
629
00:33:07,304 --> 00:33:08,038
But especially
630
00:33:08,038 --> 00:33:08,558
if it's.
631
00:33:09,443 --> 00:33:12,252
difficult to get a hold of, and the
patient just continues to worsen
632
00:33:12,252 --> 00:33:13,662
from a neurologic perspective.
633
00:33:13,662 --> 00:33:15,972
They do have a much higher
chance of mortality.
634
00:33:16,392 --> 00:33:16,902
Sam: Perfect.
635
00:33:17,312 --> 00:33:17,582
Okay.
636
00:33:17,582 --> 00:33:21,712
So in this patient population sometimes
we're worried about seizures or seizures
637
00:33:21,712 --> 00:33:23,602
occurring after the brain injury.
638
00:33:23,632 --> 00:33:24,802
How do we handle that?
639
00:33:24,862 --> 00:33:28,049
Are we still giving prophylactic
anti-epileptics, or what's
640
00:33:28,049 --> 00:33:29,159
the latest data on that?
641
00:33:29,699 --> 00:33:30,149
Dana: Yes.
642
00:33:30,419 --> 00:33:36,239
So there should be a pretty low threshold
to connect these patients to EEG, just
643
00:33:36,239 --> 00:33:39,479
because, especially if they have a
poor exam, they could have underlying
644
00:33:39,479 --> 00:33:43,929
subclinical seizures which would otherwise
be very difficult to detect, especially
645
00:33:43,929 --> 00:33:47,259
if they don't have those classic
like tonic-clonic types of movements.
646
00:33:47,539 --> 00:33:53,969
But if they don't have that in terms
of prophylaxis, the data is still not.
647
00:33:54,494 --> 00:33:59,134
The best, but at least according to
the Brain Trauma Foundation , Keppra
648
00:33:59,224 --> 00:34:03,784
and Phenytoin are still the most
common seizure medications that we use.
649
00:34:04,074 --> 00:34:07,534
And , the recommendation
is up to seven days.
650
00:34:07,569 --> 00:34:08,769
Post-injury.
651
00:34:08,989 --> 00:34:13,079
There was a pretty large meta-analysis
that was done and it found no
652
00:34:13,079 --> 00:34:16,859
association between early seizure
prophylaxis, so that seven day
653
00:34:16,859 --> 00:34:22,899
period and the 18 to 24 month risk of
epilepsy all cause mortality in adults.
654
00:34:23,179 --> 00:34:25,849
So it actually would be interesting
to see what research in the
655
00:34:25,849 --> 00:34:28,219
future can show us about this.
656
00:34:28,379 --> 00:34:31,499
But it's still a little bit of a gray
area, but usually the recommended
657
00:34:31,834 --> 00:34:35,734
period of time for prophylaxis
for seizures is about seven days.
658
00:34:36,124 --> 00:34:36,484
Sam: Gotcha.
659
00:34:36,754 --> 00:34:37,774
Dana: And the doses vary.
660
00:34:37,774 --> 00:34:40,894
We always get asked about,
especially for Keppra, do we do, for
661
00:34:40,894 --> 00:34:43,624
example, 500 or a gram or seven 50?
662
00:34:43,824 --> 00:34:47,214
And I have not seen anything in the
literature to really distinguish
663
00:34:47,214 --> 00:34:50,394
the doses and how it eventually
affects the patient's outcome.
664
00:34:50,814 --> 00:34:51,204
Sam: Gotcha.
665
00:34:52,004 --> 00:34:56,504
And you mentioned EEG, so you're
just talking about continuous EEG
666
00:34:56,504 --> 00:34:59,564
monitoring if it's available, or
you know, if that's not available.
667
00:34:59,564 --> 00:35:02,084
Is there really any utility
in SPOT EEG testing?
668
00:35:02,864 --> 00:35:07,504
Dana: So, we highly prefer continuous
EEGs just because Spot EEGs are only
669
00:35:07,634 --> 00:35:11,294
done for about 20 to 30 minutes,
which may not capture the seizure.
670
00:35:11,294 --> 00:35:13,574
It's, you know, seizures come and go.
671
00:35:13,634 --> 00:35:18,419
It may occur once in a blue
moon, once in a day, et cetera.
672
00:35:18,599 --> 00:35:22,949
So if at all feasible, we would
prefer to do a continuous EEG
673
00:35:22,949 --> 00:35:24,899
monitoring over a spot EEG.
674
00:35:25,229 --> 00:35:25,559
Sam: Gotcha.
675
00:35:25,959 --> 00:35:26,589
Perfect.
676
00:35:26,889 --> 00:35:32,229
And then I like the tiered management
of elevated intracranial pressure.
677
00:35:32,229 --> 00:35:34,929
It's another one of those
key tables in the article.
678
00:35:34,929 --> 00:35:40,239
This is number 11, which kind of provides
you with a do now then do next approach
679
00:35:40,349 --> 00:35:41,759
Walk me through that for one second.
680
00:35:42,539 --> 00:35:46,999
Dana: Yeah, so this is hopefully also
kind of and this stems from the ED all the
681
00:35:46,999 --> 00:35:49,609
way to when the patient goes to the ICU.
682
00:35:49,979 --> 00:35:53,594
But this is kind of how we think
about when we're managing these
683
00:35:53,594 --> 00:35:57,374
patients because it is such a highly
specialized patient population.
684
00:35:57,624 --> 00:36:02,394
So just broadly with your severe
TBI patients, they are gonna come
685
00:36:02,394 --> 00:36:05,724
to the ICU, they will be sedated.
686
00:36:05,724 --> 00:36:09,954
We do these initial measures to
preliminarily decrease the ICP.
687
00:36:10,284 --> 00:36:12,324
And we have sodium goals that we aim for.
688
00:36:12,324 --> 00:36:14,904
We always wanna avoid
cerebral edema, for example.
689
00:36:14,904 --> 00:36:19,594
So we don't want to drop the patient's
sodium glucose goals because either
690
00:36:19,624 --> 00:36:24,534
being hypo or hyperglycemic is also
dangerous for the brain hemoglobin
691
00:36:24,534 --> 00:36:26,329
goal of greater than seven.
692
00:36:26,989 --> 00:36:29,639
And of course, hopefully by then
you have your at least initial
693
00:36:29,649 --> 00:36:32,085
non-contrast CT head to understand what.
694
00:36:32,085 --> 00:36:35,655
the patient's intracranial pathology
looks like, and you always want to do
695
00:36:35,655 --> 00:36:38,987
other basic ICP measures, like head
of the bed should always be at 30.
696
00:36:39,237 --> 00:36:40,497
It should be midline.
697
00:36:40,727 --> 00:36:43,477
And you'll wanna do fever
prevention as well with cooling
698
00:36:43,477 --> 00:36:45,157
blankets, Tylenol, et cetera.
699
00:36:45,937 --> 00:36:47,317
If your patient develop.
700
00:36:47,722 --> 00:36:48,982
Elevated ICPs.
701
00:36:48,982 --> 00:36:52,752
That's when the previously discussed
hyperosmolar therapies that's when we
702
00:36:52,752 --> 00:36:57,482
would like to do that in addition to
keeping them more on the normocarbic side.
703
00:36:57,812 --> 00:37:02,322
And what's also helpful , with this
point is placing an EVD if that's
704
00:37:02,322 --> 00:37:06,292
available to also relieve that
elevated intracranial pressure because
705
00:37:06,292 --> 00:37:10,932
hyperosmolar therapy, it's a temporizing
measure, but it's not going to.
706
00:37:11,257 --> 00:37:15,187
Be effective for a long time, you
need something that's more permanent.
707
00:37:15,537 --> 00:37:19,847
And at this point also we say to
consider EEG especially 'cause the exam
708
00:37:19,847 --> 00:37:24,030
is likely poor Just to make sure that
seizures are not also contributing,
709
00:37:24,030 --> 00:37:26,100
especially to an elevated ICP.
710
00:37:26,390 --> 00:37:30,290
And if you're ICP persists, despite
all of these things, repeat the CAT
711
00:37:30,290 --> 00:37:33,720
scan and see if, the intracranial
pathology has worsened at this point.
712
00:37:34,410 --> 00:37:35,160
Tier two.
713
00:37:35,160 --> 00:37:40,750
So about the same PC O2 goal, a little
lower to try to temporarily decrease
714
00:37:40,750 --> 00:37:42,580
that elevated intracranial pressure.
715
00:37:42,970 --> 00:37:44,770
We also encourage increasing sedation.
716
00:37:44,770 --> 00:37:49,175
So for example propofol is something
that's useful, fentanyl, et cetera.
717
00:37:49,195 --> 00:37:52,490
You give little boluses,
to decrease their ICP.
718
00:37:52,877 --> 00:37:57,504
Ways that we play around with the
, cerebral perfusion pressure, so we can
719
00:37:57,504 --> 00:38:00,404
sometimes trial pressors with that.
720
00:38:00,494 --> 00:38:04,814
And you use that in conjunction with that
formula that I mentioned to try to change
721
00:38:04,814 --> 00:38:07,064
the cerebral perfusion pressure as well.
722
00:38:07,274 --> 00:38:10,464
You can paralyze the patient
to try to decrease their ICP.
723
00:38:11,264 --> 00:38:14,024
And also at this point, you're speaking
with the neurosurgeons way before
724
00:38:14,024 --> 00:38:17,294
this anyway, but now you're really
discussing decompressive surgery.
725
00:38:17,714 --> 00:38:22,324
And then finally tier three, if it's
really refractory mild hypothermia
726
00:38:22,324 --> 00:38:26,588
can sometimes be done, but really the
goal of it at this point should be
727
00:38:26,588 --> 00:38:30,068
to go for decompressive craniectomy
because you've tried all of these
728
00:38:30,068 --> 00:38:31,868
other measures and they're not working.
729
00:38:31,868 --> 00:38:32,438
So that's.
730
00:38:33,173 --> 00:38:34,748
Really the next step
731
00:38:35,625 --> 00:38:36,045
.
Sam: Gotcha.
732
00:38:36,845 --> 00:38:41,345
Well, on that note, it's always
been a mystery to me at what point a
733
00:38:41,345 --> 00:38:45,365
patient is supposed to go to surgery
or maybe would benefit from going to
734
00:38:45,365 --> 00:38:47,735
surgery based on their injury pattern.
735
00:38:48,005 --> 00:38:51,530
Do we have good published data
to guide that decision making?
736
00:38:52,330 --> 00:38:55,660
Dana: Yeah, so especially the more
recent literature that we came across
737
00:38:55,690 --> 00:39:00,250
of course nothing in medicine is black
and white, but it gave us nice cutoffs
738
00:39:00,250 --> 00:39:02,800
on when to really pursue surgery.
739
00:39:03,020 --> 00:39:04,985
I tried to outline that, especially in.
740
00:39:05,730 --> 00:39:08,820
Table 12 to really help guide with that.
741
00:39:09,080 --> 00:39:14,480
So if the, for example, the size of an
epidural hematoma is greater than 30 ccs.
742
00:39:14,810 --> 00:39:18,740
If the acute subdural is, if the
thickness is greater than 10 millimeters
743
00:39:18,740 --> 00:39:23,950
or if there's a shift if the hematoma
volume is greater than 50, or if
744
00:39:23,950 --> 00:39:26,920
there's a frontal or a temporal
lesion that's greater than 30 ccs.
745
00:39:27,585 --> 00:39:30,225
That's when we would
highly consider surgery.
746
00:39:30,345 --> 00:39:34,665
But other things also just like if their
GCS decreases by more than two points,
747
00:39:34,665 --> 00:39:40,135
if there's concerning pupil changes,
or the measurements that I already
748
00:39:40,135 --> 00:39:43,895
mentioned, and those are really reasons
to highly, highly consider taking a
749
00:39:43,895 --> 00:39:46,235
patient for a surgical intervention.
750
00:39:46,535 --> 00:39:46,655
Sam: Gotcha.
751
00:39:47,455 --> 00:39:51,825
Yeah, this is , a very helpful table,
honestly, because there again, in resource
752
00:39:51,825 --> 00:39:55,875
constrained areas you may not always have
a neurosurgeon around, and if you've got
753
00:39:55,875 --> 00:40:01,275
someone waiting for transfer, it helps
to be able to include this detail in
754
00:40:01,275 --> 00:40:03,630
the conversation and say, we have a CT.
755
00:40:04,275 --> 00:40:07,815
It shows an epidural hematoma
of this specific volume.
756
00:40:08,045 --> 00:40:11,795
And then you hopefully will not be
surprised with the response you get
757
00:40:11,795 --> 00:40:13,685
back based on that information from
758
00:40:13,685 --> 00:40:14,561
looking at this table.
759
00:40:14,561 --> 00:40:15,875
So you can kind of expect,
760
00:40:15,875 --> 00:40:20,265
Sam: okay, this person needs to be
expedited to get to this tertiary
761
00:40:20,265 --> 00:40:23,565
center to get neurosurgical
intervention while this other person
762
00:40:23,565 --> 00:40:26,745
maybe has time to wait and we can
optimize with medical therapies.
763
00:40:27,315 --> 00:40:28,035
Dana: Exactly.
764
00:40:28,035 --> 00:40:28,275
Yeah,
765
00:40:28,975 --> 00:40:29,515
Sam: That's great.
766
00:40:29,515 --> 00:40:31,195
This is very, very helpful.
767
00:40:31,665 --> 00:40:34,985
And then in general, what's the
general prognosis for patients
768
00:40:34,985 --> 00:40:39,305
who have moderate versus severe
traumatic brain injury nowadays?
769
00:40:40,105 --> 00:40:40,435
Dana: Yeah.
770
00:40:40,485 --> 00:40:43,170
So it depends on which
classification we use.
771
00:40:43,250 --> 00:40:45,810
I try to outline some of
the classifications and what
772
00:40:45,810 --> 00:40:47,220
the percent mortality is.
773
00:40:47,220 --> 00:40:50,737
Of course, there's always going to
be some slight variation with it.
774
00:40:51,027 --> 00:40:55,617
But if they really do have a catastrophic
brain injury with a really poor GCS
775
00:40:55,617 --> 00:40:57,947
score it can be in the range anywhere.
776
00:40:57,947 --> 00:41:00,767
I believe I put between 70 to 90%.
777
00:41:00,767 --> 00:41:04,247
Unfortunately, the patients
may, you know, not make it.
778
00:41:04,527 --> 00:41:09,817
But then again, it depends on, the
extent of the hematoma, what other injury
779
00:41:09,817 --> 00:41:11,827
there is you know, ventricular size.
780
00:41:11,827 --> 00:41:14,377
So there's a lot of components
that go into it, depending on
781
00:41:14,377 --> 00:41:18,095
which CT classification and which
clinical factors are present.
782
00:41:18,895 --> 00:41:19,345
Sam: Gotcha.
783
00:41:19,615 --> 00:41:21,355
And that's even with ideal care.
784
00:41:21,415 --> 00:41:23,575
So yeah, you've done everything right.
785
00:41:23,625 --> 00:41:26,975
, The mortality is still pretty high in
the severely traumatic brain injury.
786
00:41:27,035 --> 00:41:27,245
Okay.
787
00:41:27,515 --> 00:41:27,605
Yeah.
788
00:41:28,005 --> 00:41:29,905
And some special circumstances.
789
00:41:29,905 --> 00:41:35,399
So we all hear a lot about sports
injuries and then there is good data
790
00:41:35,489 --> 00:41:38,729
about second impact syndrome and,
you know, multiple head injuries.
791
00:41:38,999 --> 00:41:42,239
Has there been more published
on that in the recent years?
792
00:41:42,279 --> 00:41:43,389
That is helpful for us clinically.
793
00:41:44,189 --> 00:41:48,629
Dana: Yeah, so there's, especially in the
realm of chronic traumatic encephalopathy
794
00:41:48,839 --> 00:41:52,989
or CTE there has been a lot of research
that's , gone into that recently,
795
00:41:52,989 --> 00:41:57,409
especially with certain sports like,
you know, for example, like football is
796
00:41:57,409 --> 00:42:02,669
a very clear example , of, adults who
develop chronic traumatic encephalopathy.
797
00:42:02,889 --> 00:42:06,849
And there is research that's
going into how to treat it, how
798
00:42:06,849 --> 00:42:10,759
to prevent it how to optimize
safety equipment for these players.
799
00:42:10,979 --> 00:42:13,679
Just because it is something that
doesn't occur right away, but it
800
00:42:13,889 --> 00:42:16,987
happens, you know, years to decades
after the initial head injury.
801
00:42:17,467 --> 00:42:19,237
And it can really be devastating.
802
00:42:19,237 --> 00:42:19,917
And if we can.
803
00:42:20,717 --> 00:42:23,507
Find a way to prevent that,
to help 'em live longer lives.
804
00:42:23,507 --> 00:42:24,377
That would be excellent.
805
00:42:24,377 --> 00:42:28,617
So, there's certain medical centers
within the country that have entire
806
00:42:28,617 --> 00:42:32,552
labs and departments, et cetera,
that are working actively on this.
807
00:42:32,762 --> 00:42:33,722
Sam: Good, good.
808
00:42:34,502 --> 00:42:38,822
And tranexamic acid, one of those
medications, again, we're very fond of.
809
00:42:38,822 --> 00:42:41,102
It seems like it's always
looking for an indication.
810
00:42:41,262 --> 00:42:45,252
Is there benefit in giving it
early in this patient population?
811
00:42:45,652 --> 00:42:46,342
Dana: Very good question.
812
00:42:46,342 --> 00:42:50,792
So , our study that we always talk
about with this is crash three.
813
00:42:51,212 --> 00:42:53,132
So just to like briefly go over that.
814
00:42:53,132 --> 00:42:56,652
So it was a randomized clinical
trial and they included about
815
00:42:56,652 --> 00:42:58,332
12,000 patients with this.
816
00:42:58,332 --> 00:43:03,402
And they included patients who had a GCS
of 12 or an intracranial hemorrhage on CT.
817
00:43:03,912 --> 00:43:08,382
The trial suggested a reduction,
28 day head injury related death in
818
00:43:08,382 --> 00:43:09,972
patients with less severe injury.
819
00:43:10,272 --> 00:43:14,152
So what they found in the end
was that there was no benefit in
820
00:43:14,152 --> 00:43:16,642
patients who had severe injury.
821
00:43:17,002 --> 00:43:21,892
However, the other thing we worry about
with TXA is DBTs, PEs, stroke, et cetera.
822
00:43:22,222 --> 00:43:23,812
They found that patients who.
823
00:43:24,047 --> 00:43:27,977
did receive TXA did not actually have
increased rates of DVT or PE or MIs.
824
00:43:28,791 --> 00:43:31,671
So with severe TBIs there was no benefit.
825
00:43:32,150 --> 00:43:35,300
Sam: But if there is going to be a
benefit, even for the mild ones, this
826
00:43:35,300 --> 00:43:37,440
has to be given pretty early on, right?
827
00:43:37,440 --> 00:43:40,590
Within the first Few hours or three
hours I think it was of injury.
828
00:43:41,010 --> 00:43:42,030
Dana: Yes, exactly.
829
00:43:42,300 --> 00:43:42,660
Sam: Gotcha.
830
00:43:42,960 --> 00:43:43,230
Okay.
831
00:43:43,660 --> 00:43:46,210
All right, well that's a
lot of stuff we've covered.
832
00:43:46,340 --> 00:43:50,630
Thank you very much for joining us on
the podcast to discuss the article.
833
00:43:50,630 --> 00:43:54,500
Again, this is The March issue
of emergency medicine Practice on
834
00:43:54,500 --> 00:43:58,060
the ED Evaluation and Management
of severe traumatic brain injury.
835
00:43:58,060 --> 00:44:00,550
There's more in this article
that we didn't touch on.
836
00:44:00,790 --> 00:44:04,910
Lots of tables, lots of
figures great pictures of the
837
00:44:04,910 --> 00:44:09,440
different types of intracranial
hemorrhage and injury patterns.
838
00:44:09,440 --> 00:44:13,940
So I really encourage you to go look at
the article, read through it, and then
839
00:44:13,940 --> 00:44:15,860
of course, as always, claim your CME.
840
00:44:16,050 --> 00:44:18,510
And I'll put the link to
that in our show notes.
841
00:44:19,070 --> 00:44:23,510
And Dr. Klavansky, I wanna say thank
you so much for joining us on the show.
842
00:44:23,570 --> 00:44:24,410
It's been a pleasure.
843
00:44:24,810 --> 00:44:28,170
I really appreciate you taking the time
to teach us and share your knowledge
844
00:44:28,170 --> 00:44:29,790
with us and to author this article.
845
00:44:29,790 --> 00:44:30,540
It was fantastic.
846
00:44:31,140 --> 00:44:31,440
Dana: Of course.
847
00:44:31,440 --> 00:44:32,880
Thank you so much again for having me.
848
00:44:32,920 --> 00:44:35,140
This was awesome to write and
also to be on this podcast.
849
00:44:35,575 --> 00:44:37,395
Sam : And that's a wrap
for this month's episode.
850
00:44:37,435 --> 00:44:40,015
I hope you found it
educational and informative.
851
00:44:40,215 --> 00:44:45,075
Don't forget to go to ebmedicine.net
to read the article and claim your CME.
852
00:44:45,245 --> 00:44:48,435
And of course, check out all three
of the journals and the multitude of
853
00:44:48,435 --> 00:44:52,795
resources available to you, both for
emergency medicine, pediatric emergency
854
00:44:52,795 --> 00:44:55,065
medicine, and evidence based urgent care.
855
00:44:55,375 --> 00:44:57,345
Until next time, everyone be safe.