บทถอดความฉบับเต็มของ Severe Traumatic Brain Injury with Dr. Dana Klavansky

from the last 20 years. 72 00:03:43,372 --> 00:03:46,252 Has there been a lot published on the topic in that timeframe? 73 00:03:47,052 --> 00:03:47,382 Dana: Yes. 74 00:03:47,482 --> 00:03:50,182 So there was a lot of literature that we combed through. 75 00:03:50,512 --> 00:03:54,472 We looked for the most comprehensive literature that would actually help 76 00:03:54,472 --> 00:03:59,932 people really understand the mechanisms behind TBIs and how to treat TBIs 77 00:04:00,152 --> 00:04:03,422 because some of the literature was unfortunately not very conclusive. 78 00:04:03,422 --> 00:04:06,692 And so we were looking for more of the conclusive literature, 79 00:04:06,692 --> 00:04:08,132 like I said, how to treat it. 80 00:04:08,592 --> 00:04:11,832 The most pertinent imaging when to go for surgery. 81 00:04:11,952 --> 00:04:15,245 So thankfully, especially the more recent literature, has been 82 00:04:15,245 --> 00:04:18,687 great about that . So we had a lot of good resources to work with. 83 00:04:19,202 --> 00:04:19,772 Sam: Excellent. 84 00:04:20,572 --> 00:04:24,952 And in the pathophysiology section, there is a distinction drawn 85 00:04:24,952 --> 00:04:27,802 between primary and secondary TBI. 86 00:04:27,952 --> 00:04:29,572 Tell me more about that. 87 00:04:29,577 --> 00:04:31,932 And how that fits into our clinical practice. 88 00:04:31,962 --> 00:04:32,022 Dana: Yeah. 89 00:04:32,422 --> 00:04:33,887 So primary TBI is. 90 00:04:34,482 --> 00:04:40,707 a direct injury and the secondary brain injury is the sequela of that initial TBI. 91 00:04:41,097 --> 00:04:44,857 So, with primary TBIs, it can be an open or a closed injury. 92 00:04:44,857 --> 00:04:47,527 So, you know, either smash your head against something or you. 93 00:04:48,057 --> 00:04:52,017 In another way, you can get stabbed or a gunshot wound and things like that. 94 00:04:52,017 --> 00:04:56,035 So there's lots of different ways that a primary TBI can happen . And then 95 00:04:56,035 --> 00:04:59,665 the secondary brain injury that happens is, like I said, the sequela of it. 96 00:04:59,665 --> 00:05:04,375 So increased pressure in your brain, decreased oxygenation to your brain, 97 00:05:04,375 --> 00:05:08,945 decreased blood flow to your brain and then the process behind that cell injury. 98 00:05:08,945 --> 00:05:10,865 So the Wallerian degeneration. 99 00:05:10,930 --> 00:05:14,600 That occurs, the glutamate release that occurs which really damages 100 00:05:14,600 --> 00:05:16,250 those structures in the brain. 101 00:05:16,310 --> 00:05:18,710 So that's why there's a distinction between primary 102 00:05:18,710 --> 00:05:20,180 and secondary brain injury. 103 00:05:20,570 --> 00:05:20,960 Sam: Gotcha. 104 00:05:21,500 --> 00:05:26,870 And then there is also a discussion of the various types of hemorrhage 105 00:05:26,870 --> 00:05:28,700 and hematomas that can occur. 106 00:05:29,090 --> 00:05:33,050 None of that though, has changed as far as definitions in the

last couple of decades. 107 00:05:33,200 --> 00:05:36,830 What we know as subarachnoid hemorrhage, epidurals, and subdurals 108 00:05:36,950 --> 00:05:38,750 is still the standard definition. 109 00:05:39,405 --> 00:05:40,755 Dana: Yes, they're still the same. 110 00:05:41,175 --> 00:05:41,565 Sam: Excellent. 111 00:05:41,775 --> 00:05:44,600 And the epidemiology section. 112 00:05:44,600 --> 00:05:47,540 This is the part that always fascinates me the most, but you already mentioned the 113 00:05:47,540 --> 00:05:52,370 number of patients per year in the US and, the male predilection versus the females. 114 00:05:52,370 --> 00:05:57,770 But, I did find it interesting that there are like almost 50,000 deaths each year 115 00:05:57,780 --> 00:06:01,520 attributed to isolated traumatic brain injury, which is a pretty high number 116 00:06:01,520 --> 00:06:03,690 of people with significant injuries. 117 00:06:03,940 --> 00:06:07,574 and half of those deaths occur just in the first few hours after injury. 118 00:06:08,044 --> 00:06:10,471 And then there's a pretty significant population of them 119 00:06:10,471 --> 00:06:11,821 occurring in children as well. 120 00:06:12,391 --> 00:06:12,781 Dana: Yeah. 121 00:06:13,471 --> 00:06:14,671 So there are several factors. 122 00:06:14,671 --> 00:06:17,251 So it depends of course, on the mechanism of the injury. 123 00:06:17,461 --> 00:06:21,271 Some injuries are just irreversible, catastrophic injuries, and that's 124 00:06:21,271 --> 00:06:23,431 why they die in the first few hours. 125 00:06:23,711 --> 00:06:27,521 And then it also depends on what resources you even have. 126 00:06:27,921 --> 00:06:31,021 You know what hospital you go to and things like that. 127 00:06:31,021 --> 00:06:35,001 Some hospitals are incredibly specialized at treating these traumatic brain 128 00:06:35,001 --> 00:06:39,891 injuries, but unfortunately, in more remote areas, the closest hospital or any 129 00:06:39,891 --> 00:06:44,301 hospital in the area just may not be as well equipped to handle these severe TBIs. 130 00:06:44,571 --> 00:06:47,301 So , the treatments that a person receives will also affect it. 131 00:06:47,611 --> 00:06:48,451 And unfortunately. 132 00:06:48,791 --> 00:06:52,781 Yes, children also do develop these severe TBIs, and that can be from 133 00:06:53,051 --> 00:06:57,791 injury from either accidental injury or injury from others and things like that. 134 00:06:57,791 --> 00:06:59,891 So those do unfortunately also happen. 135 00:07:00,101 --> 00:07:03,881 And there's even less literature on how to treat children with TBIs. 136 00:07:04,181 --> 00:07:10,341 So, we know less unfortunately on what numbers to aim for intracranial monitoring 137 00:07:10,341 --> 00:07:11,631 and all those things for children. 138 00:07:12,431 --> 00:07:12,821 Sam: Gotcha. 139 00:07:13,461 --> 00:07:16,996 And I saw in the issue there's a table, table one, which kind of 140 00:07:16,996 --> 00:07:20,696 discusses the most

common etiologies for traumatic brain injury, putting 141 00:07:20,726 --> 00:07:22,506 fall at the top of that list. 142 00:07:22,516 --> 00:07:26,766 for all populations, all ages and then direct trauma and motor vehicle 143 00:07:26,766 --> 00:07:28,626 collisions being the third most common. 144 00:07:29,046 --> 00:07:33,516 There is a distinction now between mild and the moderate to 145 00:07:33,516 --> 00:07:34,806 severe traumatic brain injuries. 146 00:07:35,331 --> 00:07:36,711 Tell me about that classification. 147 00:07:37,111 --> 00:07:37,391 Dana: Yeah. 148 00:07:37,901 --> 00:07:42,955 So between a mild, moderate, and severe, it really depends on the duration of loss 149 00:07:42,955 --> 00:07:45,385 of consciousness and duration of amnesia. 150 00:07:45,845 --> 00:07:49,975 So with moderate and severe, there's a loss of consciousness 151 00:07:49,975 --> 00:07:52,785 that's, a greater than 24 hours. 152 00:07:52,785 --> 00:07:57,675 And your GCS score is much lower on the spectrum as opposed to mild TBI where 153 00:07:57,675 --> 00:07:59,369 your loss of consciousness is very brief. 154 00:07:59,399 --> 00:08:03,054 It's like 30 minutes . amnesia is also less than 24 hours. 155 00:08:03,054 --> 00:08:07,194 So you're transiently altered, but you essentially get back to your baseline. 156 00:08:07,314 --> 00:08:11,852 But with moderate and severe TBI you do not get back to your baseline essentially. 157 00:08:12,739 --> 00:08:13,219 Sam: gotcha. 158 00:08:13,429 --> 00:08:16,369 It, it's funny 'cause I actually wouldn't consider that to be mild in 159 00:08:16,369 --> 00:08:20,599 general practice if somebody said they were actually out for 25 minutes or so. 160 00:08:20,599 --> 00:08:23,269 But 30 minutes is the general accepted guideline there. 161 00:08:23,539 --> 00:08:24,169 Dana: Exactly. 162 00:08:24,409 --> 00:08:24,619 Sam: Okay. 163 00:08:25,039 --> 00:08:25,609 Good to know. 164 00:08:25,979 --> 00:08:30,269 And then there is also in the classification, a distinction 165 00:08:30,269 --> 00:08:33,959 between impact versus Non-contact or inertial loading. 166 00:08:34,009 --> 00:08:36,619 which is actually not terminology I'm accustomed to using in 167 00:08:36,619 --> 00:08:37,399 the emergency department. 168 00:08:37,399 --> 00:08:38,239 Tell me more about that. 169 00:08:38,689 --> 00:08:38,869 Dana: Yeah. 170 00:08:38,869 --> 00:08:42,659 So, the way I can kind of describe it, it might not be the best, honestly. 171 00:08:42,849 --> 00:08:45,849 But the way I can describe it is that, like you said, there's two kinds. 172 00:08:45,849 --> 00:08:48,289 So there's impact loading and also inertial loading. 173 00:08:48,289 --> 00:08:53,392 So impact loading it produces more focal injuries like local skull fractures, 174 00:08:53,542 --> 00:08:58,832 epidural hematomas and inertial loading is more of a diffuse injury of the brain. 175 00:08:59,072 --> 00:08:59,552 So. 176 00:08:59,742 --> 00:09:01,722 Concussions are more

of a diffuse injury. 177 00:09:02,022 --> 00:09:05,502 Subdurals can be very large and encompass essentially the outer portion 178 00:09:05,502 --> 00:09:07,682 of the entire half of the hemisphere. 179 00:09:07,842 --> 00:09:09,162 So that's what the difference is. 180 00:09:09,162 --> 00:09:12,822 And diffuse axonal injury, which is a secondary brain injury. 181 00:09:12,822 --> 00:09:15,962 So , the difference is more focal versus more of a diffuse injury. 182 00:09:16,232 --> 00:09:16,562 Sam: Gotcha. 183 00:09:17,362 --> 00:09:19,402 And then when we talk about. 184 00:09:19,777 --> 00:09:21,697 All things on this podcast. 185 00:09:21,697 --> 00:09:25,057 We always mention the differential diagnosis, but really this is quite broad. 186 00:09:25,057 --> 00:09:27,937 It's just a differential diagnosis for altered mental status. 187 00:09:27,937 --> 00:09:33,217 So anything from intoxication to dehydration, to infection, 188 00:09:33,217 --> 00:09:36,947 anything you can think of that might cause altered mentation even, you 189 00:09:36,947 --> 00:09:38,327 know, hypoglycemia for example. 190 00:09:38,327 --> 00:09:39,647 All of that is on the list. 191 00:09:39,867 --> 00:09:41,547 As far as the differential is concerned. 192 00:09:42,057 --> 00:09:46,917 For our colleagues who are listening who work in the pre-hospital arena 193 00:09:47,197 --> 00:09:51,457 is there anything new or maybe even just critically important that 194 00:09:51,457 --> 00:09:55,867 we would encourage them to do as pre-hospital providers in EMS agencies? 195 00:09:56,597 --> 00:09:59,807 Dana: As you mentioned, it's a very broad differential for these patients, 196 00:09:59,807 --> 00:10:03,557 so I would just keep an open mind when you're working these patients up 197 00:10:03,557 --> 00:10:08,807 as to, other concurrent issues that might be going on along with the TBI 198 00:10:08,987 --> 00:10:13,517 because it's very easy and I'm sure it happens very often, that people think, 199 00:10:13,517 --> 00:10:18,017 oh, this person has a TBI, they were in insert blank, you know, accident. 200 00:10:18,167 --> 00:10:19,427 We are going to treat them for that. 201 00:10:19,637 --> 00:10:23,307 But it's also very important to correct other metabolic etiologies, 202 00:10:23,957 --> 00:10:28,502 other electrolyte abnormalities, arrhythmias ensure that you're not 203 00:10:28,502 --> 00:10:30,722 missing any seizures, for example. 204 00:10:30,882 --> 00:10:34,872 Because a lot of other concurrent issues could have also caused this. 205 00:10:35,082 --> 00:10:39,402 And if they're missed, it could, you know, prove to be pretty catastrophic later. 206 00:10:39,652 --> 00:10:43,792 So having a very low threshold , for doing a broad workup for why the TBI 207 00:10:43,792 --> 00:10:48,732 happen is essentially as important almost as treating the TBI itself. 208 00:10:49,512 --> 00:10:49,992 Sam: Good to know. 209 00:10:50,527 --> 00:10:57,297 And if they are on scene and our medics are there , the initial GCS is a critical 210 00:10:57,297 --> 00:11:02,497 piece of information to gather and report along with their initial vitals and, 211 00:11:02,497 --> 00:11:05,707 you know, making sure that information is relayed to our emergency providers. 212 00:11:05,707 --> 00:11:08,777 I noticed that you mentioned, blood pressure, oxygen measures 213 00:11:08,777 --> 00:11:10,607 taken, especially in the field. 214 00:11:11,027 --> 00:11:14,902 that there is a lot of debate always about stabilizing patients 215 00:11:14,902 --> 00:11:18,382 on scene, how much time you take on scene versus, you know, how quickly 216 00:11:18,382 --> 00:11:20,122 you can get them to a hospital. 217 00:11:20,212 --> 00:11:23,752 Is there anything new in that arena as far as evidence goes? 218 00:11:23,752 --> 00:11:26,212 Or, did you find anything helpful as far as data goes? 219 00:11:26,932 --> 00:11:29,362 Dana: Yeah, so there have been multiple studies that I've looked 220 00:11:29,362 --> 00:11:33,312 at this, . There's for example, the Epic study which was the excellence 221 00:11:33,312 --> 00:11:35,442 in pre-hospital injury care study. 222 00:11:35,562 --> 00:11:40,752 So , in this study, they included over 21 patients with TBIs. 223 00:11:41,002 --> 00:11:43,772 And they were separated by different categories. 224 00:11:44,012 --> 00:11:48,326 And then what they looked at was, you know, pre-hospital outcomes along TBI 225 00:11:48,476 --> 00:11:52,584 categories , as I said, and there was greatest benefit among stabilizing 226 00:11:52,584 --> 00:11:55,284 these patients if they had severe TBIs. 227 00:11:55,624 --> 00:11:59,044 There was also the OPALS study, which was done in Canada. 228 00:11:59,314 --> 00:12:02,854 So this was the Ontario Pre-Hospital Advanced Life support study. 229 00:12:02,914 --> 00:12:05,894 And it compared outcomes with life support. 230 00:12:05,944 --> 00:12:09,164 Either the patient got life support measures on the field, including 231 00:12:09,164 --> 00:12:13,754 intubation, so pre-hospital care versus while they got to the hospital and there 232 00:12:13,754 --> 00:12:18,734 was really no decrease in mortality after they implemented the pre-hospital care. 233 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.