Professional Documents
Culture Documents
Objectives
What is Traumatic Brain Injury Management of TBI Specific target in the management of TBI Should ICP or Metabolic parameter as target ?
Definition
Traumatic brain injury an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, or both
Mechanisms of injury
Primary brain injury
inflammation
apoptosis
necrosis
Brain trauma
cytokines
Eicosanoids endocannabinoids
Acetyl Choline
ROS
polyamines
Calcium
Physiology : CPP
CPP = MAP ICP (CPP<70mmHg : poor outcome following HI) MAP>90mmHg and ICP<20~25mmHg
ICP
ICP control/ management initial treatment become important to maintain sufficient CPP to deliver O2 and nutrient to brain cells
Intracranial hypertension only independent variable predicting cerebral infarction ( OR 13.27 ; CI 2.8- 62.6 ) ICU mortality was significantly higher in patients with cerebral infarction ( OR 3.87 ; CI 1.1-14.2 ) 3 patients cerebral infarction developed after operative decompression ( total patients 89 )
Neurology 67 October 2006
C. Effector site
Sympathetic nerv syst
Adrenal medula Epinephrn norepinephr Cortison, aldostr, G.H
Hypothalamus
Kidney
Renin, angiotens
Pancr islets
ADH
Aldostrn
Glukagon Insulin
Metabolic parameter
PaO2, PaCO2, pH Cerebral lactate concentration AjVDO2 ( arterial venous jugular bulb oxygen saturation) SjO2
Robertson et al
That is not always true in patient with ischemia His study revealed that changes in AjVDO2 were poorly correlated with changes in CBF However if a correction is made for the presence of ischemia, based on low CBF or increase venous lactate concentration the correlation between CBF and AjVDO2 improved to r = 0.74 They suggest that a cerebral lactate oxygen index less than 0.08 serve as a reliable indicator of ischemia And this index provides a significant indicator of outcome
Neurosurg 1998- 70 ;22
Robertson et al
Changes in SjO2 reflect dynamic CBF SjO2 < 40% associated with development of EEG abnormalities, neurologic deterioration, unconsciousness, and depletion of cerebral energy stores indicating cerebral ischemia This result confirm that monitoring SjO2 indicates critical cerebral perfusion - and cerebral consumption
Conclusions
For a better patient outcome use Pressure targeted and cerebral metabolic parameter !!! Example : hyperventilation ICP decrease but it was confirmed by SjO2 associated with worsened CBF