Combined TBI & hemorr.shock

[Ivan Hronek]

Mike, CNS injury - if it is severe - (and if the patient is comatose it probably is) is crucial for survival, it takes second place after the heart: everything else comes a distant third. 
 
So 1. keep the heart beating
     2. keep the CNS perfused
 
In other words, in cases of serious TBI permissive hypotension takes second place after CNS perfusion pressure and you have to keep the MAP higher to overcome the ICP. It's not really a problem as this used to be and still is in some countries and regions the approach to trauma patients - flood them with fluids - and the results as of dr. mattox's study were just slightly worse than with delayed fluid resuscitation.
 
The best way to do that might be to use hypertonic saline and blood products and restrict crystalloids - just as there is a tendency to do in all severe trauma nowadays. You will also have a lower threshold to use vasopressors instead of crystalloids. http://www.ncbi.nlm.nih.gov/pubmed/1994077
 
http://www.trauma.org/index.php/main/article/392/
Hypoxia and hypotension are the greatest threat to functional outcome in brain injury. Early acute control of the above three parameters may have more impact than all other measures subsequently employed. Progressive neuronal loss occurs from the time of injury, not the time of arrival in hospital. Hypovolaemia and hypotension must be corrected early and take priority over other interventions for the brain injury. Other injuries causing haemorrhage must be addressed first (or simultaneously) so that an adequate cerebral perfusion pressureis maintained. Patients should be kept sedated to prevent coughing or valsalva maneuvers from fighting the ventilator, as these increase intracranial pressure.
 
 
http://www.cps.ca/english/statements/EP/ep90-01.htm
 Ivan Hronek MD                                                                              
Los Angeles, CA 
http://health.groups.yahoo.com/group/Anesthideas/    
                                          Do not fear to be eccentric in opinion, for every opinion now
accepted was once eccentric. - Bertrand Russell-
________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 
________________________________
 



----- Original Message ----
From: "Bjorn, Pret" <pbjorn at emh.org>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Monday, June 30, 2008 6:06:29 AM
Subject: RE: TBI question

Mike, 

Your instincts are correct.  There is no protocol specific to these patients, because these cases are complex balancing games.

Think of "permissive hypotension" as mostly a matter of a) dispensing with blood pressure as a useful marker of perfusion, and b) admitting that fluids are not a logical remedy for real and refractory hypoperfusion in trauma.  

The practical upshot is that yes, your head-injured patient will suffer mightily for every minute of inadequate systemic perfusion; but fluids offer only fleeting (if any) remedy, and with predictable costs on the other end.  As with all of the conventional, historical, and occasionally hysterical approaches to severe brain injury (mannitol, hyperventilation, steroids...) temporizing measures are at best debatable, and of no use at all if you're any distance from a decent general/trauma surgeon.

1. Airway, Breathing, and Acceleration.  
2. Set course for a trauma surgeon.
3. Call a neurosurgeon once the injuries to the brain are of a DIRECT variety.

There's your protocol.

Pret Bjorn, RN
Bangor, ME USA


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Mike Smertka
Sent: Monday, June 30, 2008 12:01 AM
To: Trauma & Critical Care mailing list
Subject: TBI question





Hello again everyone.
 
I just finished reading an article on TBI and was hoping somebody here would help me out. It seems to me that in a multisystem trauma (serious enough to require surgical intervention) where there is also a head injury, treatments like permissive hypotension and preventing secondary brain injury are at odds. Does it become some sort of complex balancing game, or is there a protocol that I haven’t seen yet on the matter? Any input would be greatly appreciated.
 
Mike


      
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/