Thank you for joining us today. I am Kim Berry. I am a member of the TCAA's Education Committee, and it is my pleasure to be moderating this webinar today titled Traumatic Brain Injury, the Initial 48 Hours. This is part of our TBI series, and I hope that you will have the opportunity to watch all of the webinars in this series. Joining us today to talk about initial management of traumatic brain injury is Dr. Lena O'Keefe from Yale University School of Medicine. Dr. O'Keefe is a board-certified neurointensivist at Yale New Haven Hospital and was recently promoted to assistant professor. She completed neurology residency at Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated hospital, followed by Neurocritical Care Fellowship at UT Houston, which is one of the busiest neurotrauma centers in the United States. She has a master's degree in neuroscience and has many publications in translational stroke research. So I want to thank her for joining us today and being willing to share her expertise and her time. And with that, I will pass it off to Dr. O'Keefe. Thank you, Kim, for that very nice introduction. I appreciate it and happy to be here. During my fellowship time, I did see a lot of trauma. I still see it to this day, and I'm happy to share all of my insight with all of you. I have no disclosures. And the reason why we wanted to talk about this topic is because traumatic brain injury, moderate to severe, which is really defined as a GCS of three to 12, represents a high amount of people in the US and 30% of all injury-related mortalities. And that number comes out to around like 60,000 Americans. The way I decided to present this is through some cases, all of which are patients I've seen within the past couple of months. That's how frequently we see this. And within each case, I'm going to talk about certain pearls, but the major topics that I wanted to cover are when patients should go to surgery or have an intracranial monitor, what to do when someone's on an anticoagulation medication or an antiplatelet, what do we do with anti-seizure medications, how do we pick our sedation and some of our analgesia, and really the beginning stages of how to treat high intracranial pressure. All of my references are based on current guidelines and trials. The ones that you're going to see the most often referenced are the Brain Trauma Foundation, Neurocritical Care Society, and we even have some American Association for Surgery of Trauma Critical Care Committee as well. So we'll start with case one. This is a 25 healthy male who was unfortunately in a motor vehicle accident. When EMS got to the scene, he was a GCS 14. The one point was taken off for confusion, but his pupils at that time were equal round and reactive to light. He's moving all of his extremities. He gets to the ED. Now he's a little bit more agitated, still a little bit confused. When he's not agitated, he prefers to keep his eyes closed, but he opens them readily to voice. He's following some simple commands. You know, if you tell him to lift his arm, he'll do that, but more complex things he's not doing. And he has a little bit of left arm weakness. So this puts him at a GCS of 12. It has a little bit of tachycardia, a little bit elevated blood pressure, most likely in the setting of his agitation, but he is given some Haldol and Versed, but the agitation still gets worse and he really can't sit still for imaging. So he is ultimately intubated. We get his scan and this is what we see. This is a CAT scan of the brain. And just as a refresher, left is on the right of the screen, right is on the left. And I have some measurements in here. And what we see on the right side that's being measured as 9.5 millimeters is an epidural hematoma. So we talk about epidural versus subdural hematoma. So I'm gonna pause for a second and sort of talk about the difference between that. The way epidurals manifest is most often it's an injury of the middle meningeal artery. So it's an arterial bleed and often happens through a skull fracture that you can see here. And actually on this bone window, he has a skull fracture right here. It's harder to see on the brain window. Whereas a subdural hematoma is actually due to a rupture of the bridging veins between the dura and the skull, sorry, between the dura and the brain. And whereas the epidural is between the skull and the dural space. And because of that, you get two kind of different phenotypes in the way they look. Sorry about that. And I've seen a lot of people reference kind of, you get a lemon shape for the epidural and a more of a banana shape for the subdural. And that's just the way that it's able to kind of fill in between the brain, whereas this is an arterial brain and pushing the brain down. I just wanna go over some other nomenclature that we often use when describing the injuries in a traumatic brain injury. So we talked about the epidural hematoma. This is the same patient. This scan is just a little bit lower down in the brain. And you can still see that he has an epidural here and an epidural here. This big green circle is what we refer to as a contusion. So it means it's bleeding really in the parenchyma of the brain. And think of that more of a bruise. And then these red arrows kind of denote what's called diffuse axonal injury. And that's usually due to like shearing of the nerves itself. So one of the first questions you have to ask and get involvement with your neurosurgeon is when should we operate? And the Brain Trauma Foundation has put out guidelines of when you should definitely operate. And these are kind of the parameters that they've come up with for an epidural hematoma. So any hematoma that's greater than 30 centimeters cubed, regardless of the GCS, a thickness that's greater than 15 millimeters and midline shift, which is greater than five millimeters. And so now I'll go back over here. The way we measure midline shift is we put a line from each end of the skull at the level usually of the third ventricle, which where the right side of the measurement is sitting. And then you kind of see how far off that shift is. And for this person, it's four millimeters. And then oftentimes if there's an epidural and they're comatose less than GCS of nine, you're gonna operate as well. So currently this man doesn't actually meet criteria for surgical evacuation, but there are other times we consider surgeries, whether or not there's the presence of anisocoria, meaning the pupil sizes are unequal. And for him, we said that the pupils were equal in the field, they were so, say in the ED evaluation and sometimes in the temporal lobe, which I can go back a slide. This is the temporal lobe here. And the reason why that can be problematic is because this is where some early herniation can occur and press on the brainstem here. And that's when you start to see the dilation of the third nerve or the pupil because it compresses the third nerve, which one's right along here. In the meantime, while you're having your surgeon evaluate the patient, review the imaging, you're gonna do Q1 hour neurochecks including pupils, because like I said, the pupils are sort of the gateway to the patient having early herniation. Lethargy is another sign. So those are the things that you're really going to be checking for. And then seizure medication in traumatic brain injury patients. Initially, when the Brain Trauma Foundation initially came out with guidelines in 2006, they said that phenytoin was seen to decrease the incidence of early seizures. And that means seizures from the time of injury to day seven, but it was not recommended to use an anti-seizure medication after seven days. That didn't have any beneficial effect. And most time the seizures are really gonna occur in the first seven days because blood is very irritating to the brain. Now, there've been lots of different studies about using different medications and Keppra is something that's readily available and really doesn't have much in terms of side effects. And the only thing that, it is renally cleared. So you do have to dose it to a patient. Renal function, but most of the time we usually give a gram as a load when they first arrived to the ED. And then usually the maintenance dose is between 500 and one gram, 500 milligrams, one gram every 12 hours for seven days. And that's from the Neuro-Critical Care Society guidelines. The other thing is when to check in again. So we have, you know, your initial scan and then serial scans, we usually do between four and six hours. And this is gonna be very institution dependent. This is gonna be neurosurgeon and Neuro-Critical Care expertise dependent and patient dependent. If someone's on anticoagulation or, you know, they're younger and have a higher risk of expanding that bleed, but not enough, a lot of room in the skull because they have fuller brains when you're younger, we might, you know, say get it closer to the four hour mark. Or if you don't have, you know, a very good neuro exam that you can follow for deterioration. If the patient's stable, it's kind of a small bleed, then oftentimes, you know, we'll say you can wait the six hours. Of course, with the caveat, if something were to change in the neuro exam, we would go sooner for a scan. The other thing is you wanna actually check the vasculature. This is a rare complication. It happens in less than 1% of traumas, but it can cause strokes. And so obviously that is, you know, can be permanently disabling. And so that's why we check in. There's a Denver grading scale, kind of with increasing, you know, level of occlusion versus transection being at the bottom here. The first two grades being like kind of more of the minimal injury. Most of the time, the treatment for that is gonna be aspirin 325 for three months. But there are some times where you're gonna do some anticoagulation if it's appropriate for the patient, followed by aspirin for six weeks. And most of the time, that's gonna be in your higher grades injury and the ICA stands for internal carotid artery and a VA stands for your vertebral artery. In terms of chemical prophylaxis for blood clots and things like DBTs and PEs, usually we start them 24 hours after a surgery if they've gone for surgery or from stable imaging, meaning they've had at least two images where the bleeding looks approximately the same. And then in terms of when do we start aspirin, it's usually about the same time you start the chemical prophylaxis. But again, that's also pending whether or not they have an upcoming surgery. Maybe they have to have, you know, a femur fracture repaired or something like that. And so oftentimes we usually wait until after all surgeries are completed. So now the patient has gone up from the ED to the ICU and the nurse is telling you he's no longer opening his eyes, even though she's sternally rubbing him, he's not following any commands and his right pupil is dilated and now it's sluggish. And now that left arm weakness that was sort of mild is much more pronounced, he's not moving it at all. For someone who is not neurologically trained, I figured it's important to kind of go over what are normal pupil measurements. Most of us have pupil sizes between two and four millimeters. If you have a pupilometer, the reactivity, meaning what do we consider brisk, is really greater than three. It's a random number scaling that we've come up with. And the other question we get a lot is symmetry. You can have a physiologic difference of up to one millimeter, but this is important, take this with a grain of salt. In someone who you could expect to have a dilated pupil, if you have a known injury on the right side, like this gentleman, if that right pupil starts to get larger, that's probably not physiologic. And especially with him becoming more sleepy and things like that, that's probably problematic. There's increased pressure there. And so here's his initial scan that we saw. And this isn't his scan. He actually did not end up having to go to surgery, so I used an online picture. But now we can see that this epidural has expanded quite a bit. It's definitely gonna meet the threshold for greater than 15 millimeters. And now this midline shift has worsened as well. So what are you guys gonna do to prepare him on the way to the OR? These are some therapies that we implement. And some of them are very simple, but often forgotten, is elevating the head of bed. Sit that patient upright. Don't have him leaning back at like 30 degrees. Have them up at like 60, 90, best you can. Make sure their neck is straight. You wanna make sure that they have good venous drainage from their internal jugular veins down. And if your head's turned to that, you can kink that off. So these are small things, but they can be very helpful. Hyperosmolar therapy. Depending on your institution, they have different names. At Yale, we call them bullets. At UT Houston, we call them salt bombs. But really what's in them is 23.4% sodium chloride. And you can give anywhere between 30 to 60 cc's. And one salt bomb or bullet is 30 cc's. And those you push over one to two minutes. You can push a little faster, but the reason why we recommend pushing it over one to two minutes is you can see hypotension with that and sometimes some bradycardia. So if your patient, you're pushing it and they seem to tolerate it, they're not having any fluctuations in their hemodynamics, you can go a little faster. The important thing to know is that 23.4% works within minutes. Manitol, you can give. The dose is usually between one to 1.5 grams, not milligrams, grams per kilogram. But Manitol usually takes at least 15 to 20 minutes before it's gonna have any effect. So while this is gonna help, it's not gonna be the thing that's gonna help right away. And the important thing to know is you have to push it through a filter to catch any of the crystals that might form from the sugar itself. And we usually do this, run it over 30 minutes. The other thing is if the patient is intubated on a ventilator, you can hyperventilate them with your goal PaCO2 being between 30 and 40. There's been a lot of literature that looks at what happens if you go below that. And really the thing is, is you're trying to cause some vasoconstriction to give more room in the skull. And if you vasoconstrict too much, you can cause a stroke as well. So that's why we usually don't recommend going further than that. On to the next case. So this is a 75-year-old gentleman. He's independent at baseline. He has atrial fibrillation for which he's on a PIXA band. You know, has some other vascular risk factors and tripped on the edge of his carpet and hit his head on the counter on the way down. He gets to the emergency room. He's lethargic. He's only oriented to himself. He's following some simple commands. His speech is clear, but most of what he's saying is kind of nonsensical. You know, just kind of a word salad. And he's not really moving his right side. Blood pressure is 140 over 70. We get a CAT scan and this is what we see. Caveat being, I take care of patients like this all the time. This image is from the internet because for some reason the past couple months I haven't had an acute subdural. So for this one, I don't have measurements. And the reason why I'm saying that is because now we're gonna talk about who's an operative candidate for acute subdural hematoma. So this is a little bit different than an epidural. An epidural is 15 millimeters, but for a subdural it's 10 millimeters. This guy would definitely meet the criteria of greater than 10 millimeters. And same amount of midline shift, it's five millimeters. And again, if we were to draw the line here down straight and then measure from the midline over to like where the third ventricle would be, that is definitely gonna be greater than five millimeters. And same thing if the patient's comatose less than GCS of nine, and generally have one of these other, um, or meet one of these other parameters as well. Mostly if the GCS is decreased by two points, that means, you know, that the bleed is, uh, increasing in size, most likely and having, um, significant mass effect and asymmetric or fixed and dilated people. If you happen to have an intracranial monitor in, um, because this person came in with a, a non-operative, um, subdural at first and you want to keep an eye on it, ICP greater than 20 would also be a threshold. So, um, for this case, we're going to talk about, um, blood pressure and anticoagulation pearls. Um, there actually are not a lot of good blood pressure recommendations, surprisingly, um, in the brain trauma foundation guidelines, they have a class three recommendation. So very weak evidence that they say in a systolic blood pressure greater than 100, if you're aged 50 to 69 or greater than 110, if you're younger than that or older than that, greater than 70, but they actually don't recommend, or they don't comment on a ceiling blood pressure. Most of us are going to say probably less than 150 if the patient is non-surgical and most surgical patients, whether or not it's for trauma or not, neurosurgeons preferred for the blood pressure to be less than 140, particularly in the perioperative period. And should we reverse someone who's on anticoagulation 99.9% of the time, the answer is going to be yes. Um, reversal for anticoagulation is going to be beyond the scope of this, um, talk, but you know, for whatever they're taking, make sure, you know, you work with your pharmacist, um, to use the right correction factor. Most of the time that's going to be PCC, but sometimes if you're on, you know, vitamin K antagonist, that's going to be vitamin K as well. Um, the one side of the reason why I'm saying 99.9% of the time is if you've come on with a very, very small bleed or, but you have, uh, like one that you can barely even see on your CAT scan, but you are on anticoagulation because you have a mechanical valve. Well, then we have to kind of weigh the risk benefits of that. And then the reversal of antiplatelets, um, really we don't recommend, um, or rather the neurocritical care society doesn't recommend transfusion, um, or correction of antiplatelet unless you're going to go to the operating room. And for most patients, they usually just transfuse, um, a pool or a pack of platelets. Um, there really is no use or evidence for the use of DDAVP. Um, however, again, if you're going to go to the OR and you can give it, um, the other time I typically would use it is if they're a uremic patient. Um, that's the one time I I've seen that DDAVP is actually beneficial, uh, but not necessarily because they're using an antiplatelet. And lastly, we'll talk about TXA. Um, and there was a trial that came out in 2019 that was published in the Lancet called CRASH-3. Um, the primary outcome was a mortality within 28 days. And this graph right here, I think is very telling of who this is beneficial for and when. So this is from the, this is, um, a graph from the trial itself. Um, and as a reminder, when you're grading TBIs by GCS, mild is going to be 13 to 15, moderate is 9 to 12, and then your severe is going to be GCS 3 to 8. And the risk ratio is really, um, the, you know, the lower this number, the more people we're going to have see benefit from it, meaning they're going to have decreased mortality within 28 days. And the sooner you give it, the better, and it really is going to help more so the people who have the mild to moderate GCS score. I think, you know, there's been some postulation of why not the severe GCS, and I think a lot of people feel that by that point, if there's a lot of blood in the brain, that's causing them to have this bad of a GCS score, then the damage is kind of already underway. And that, so that's why the salvageable people are really going to fall into this group. The other recommendation that may not be clear from this is it really should be given within three hours. And that was what was used in the CRASH-3 trial. The other thing to know about safety for it is there was no difference in rates of thrombotic events, meaning strokes, myocardial infarctions between people who got TXA and people who did not. And then here's just, you know, for your information, you load a gram over 10 minutes, and then you give another gram infused over eight hours. On to the last case, but we're going to spend a little bit more time with this case. This case is near and dear to my heart, and you will see why at the end. This is a 19-year-old female, again, healthy, and was in a car accident. On the scene, she was a GCS-3, fixed and dilated pupils bilaterally. She was somehow extricated from the car, don't know if her friend got her out or what. She had a C-collar placed and an OPA. They noticed that she had a laceration on the right side of her head, and they were trying to back her on the way to the emergency room. When she got here, she was a GCS of seven. You can see she had poor eye and verbal scores, but she was, you know, withdrawing, and so she got some points for her motor score. Agilely breathing, she was intubated. Pupils are starting to come back a little bit, and this is her scan. Now, I don't expect anybody to be able to really pick out the nuances of this scan, but I did want to show it to you just for your reference. This is the patient here, and this is actually another patient of mine around a similar age. You can see what kind of a fuller, younger brain looks like, and how we sort of look at the subtleties for cerebral edema. I'll start by pointing out some of the bleeding. So, she has some subarachnoid blood here and here. This is probably either contusion or diffuse axonal injury. She has some blood here in the front of her, like along the front of her skull and the frontal lobe, a little bit of blood here in her cisterns. And how do we kind of look for the subtleties of cerebral edema? I'm going to use this reference here. So, these are pictures, you know, roughly at the same level of the brain. In here, this is called like sulci, all this kind of black areas. So, you can see some space here within the brain, and in her, you really, you can't make that out. And same thing, kind of even up above, you see some space here, you see some space there, and for her, you don't see as much space. And also, the other thing is that in this guy, we can really see the clear delineation between the white matter, which is actually more gray on a CAT scan, and the gray matter, which is your cortex. Which is a little bit fainter on this. And for her, she actually looks like her gray matter is a little bit thicker than normal, and that's where you're going to get the bulk of your swelling if you have cerebral edema. So, what to do in terms of initial management, in terms of sedation, and some neuroprotective measures for patients in general with traumatic brain injury. We actually really like propofol. It has a quick-on, quick-off effects, so it's very useful for frequent neurochecks. Helpful if you're traveling for scans and you really don't want patients to move a lot. Helpful for OR, going into procedures. Brain injuries do hurt. If you've ever hit your head or had a concussion, you'll know that you have pain. So, you want to have some analgesics in place. So, you want to have some analgesia on board. And for those who aren't intubated but might have a little agitation, like the first case we talked about, Presidex is a great option. And again, all of these you can see are sort of quick-on, quick-off, short-acting, because we really do, in this first 48 hours, want to monitor the neuro exam very carefully. Because those who may not have been operative candidates can become operative candidates. Those who are potentially developing high intracranial pressure, we want to know so we can treat that. And then for some neuroprotective mechanisms, for brain recovery in general, you want to truly avoid fever when I say euthermia. Fever is very bad for the brain. And then these are some of the, you know, standard things. Euglycemia, PACO2 goal is normal, 35 to 45, PAO2, 80 to 150, which we're going to talk a little bit more about in the next slide. And then the blood pressure we already went over. So, for her, we talked about how she has a little bit of cerebral edema on her exam, but no real focal areas of bleeding that, you know, would make her an operative candidate. So, her exam is kind of poor. And for her, she's probably a good candidate to have an intracranial monitor. We actually don't have good guidelines for who to put monitoring in. However, it's a general consensus that people that we put monitor in are people who we think are going to be high risk for elevated intracranial pressure, which is defined as greater than 20 millimeters of mercury. Who are those typical patients? Young, younger people. And anyone who has an exam that's sort of out of proportion to their imaging. If you have a patient who has a scan sort of like hers, but say not, doesn't have the cerebral edema or anything, that would make her a little bit higher risk. But the patient has a pretty poor exam, then that's someone you might want to consider putting it in. Of course, you want to rule out other causes like blood vessel injury, because maybe they're developing a stroke. Top of the basilar is always something you have to worry about. And if they had a transection or in their vertebral artery, that can cause a clot to go to the top of their basilar. And seizures. So you always want to, maybe if your institution has a cerebral, that's a quick couple leads that you can put on and evaluate or full EEG for monitoring. Oops, sorry about that. And I told you we would talk a little bit more about oxygenation goals. And there was a trial, BOOST-2, which was a phase two randomized clinical trial. So that really means it's not powered for clinical efficacy. It's more for safety. And the goal of this trial was to look at patients who had an ICP monitor alone versus an ICP monitor plus a monitor where you can measure the partial pressure of oxygen within the brain. And that's what the PBTO2 stands for. They outlined a tiered approach to maintaining a PBTO2 of greater than 20 millimeters of mercury. Easy number to remember because it's the same as ICP, the threshold for ICP being high. But normal in people are usually 23 plus or minus seven. And what they found was that in people who had the PBTO2 monitors and then got therapy to maintain brain tissue oxygenation, we did see reduced mortality and improved neurologic outcomes at six months. So BOOST-3 is underway. That's the one to be powered for clinical efficacy. Not exactly sure when the results of that trial are going to come out. But really, it's not always about just systemic oxygenation. It's really targeting more of the brain. So for her, let's say we gave her sedation and we put in that intracranial monitor. Sorry, I didn't even mention. This is what an intracranial monitor looks like. Most of them are called BOLTs. And they really just go into the parenchyma. And so that's what it looks like on a scan. And we usually typically put them in the right frontal because the language area is on the left. So now that we've done some of our propofol for her and fentanyl for analgesia, what else can we do? Well, we sort of talked about hyperosmolar therapy on our way to the OR. You can actually schedule these therapies. But the doses are a little bit different. Usually, we only give one bullet or salt bomb. So 30 cc's of 23.4% sodium chloride. And we try to alternate it with mannitol. And as you can see, this dose is much lower, 0.25, usually to 0.5 grams per kilogram. But you can use higher doses if needed. And then kind of what are the cutoff parameters where you stop? So most of the time, a sodium of greater than 160 isn't going to have much more benefit in terms of having an effect of drying out the brain. And mannitol, we really stop when the osms get over 320. You can budge that a little bit, maybe go up to 330. And we also have to check the osmolar gap to make sure it's less than 12 in order for it to be effective because that's the way that mannitol is going to work. The other thing to remember is mannitol doesn't really work in renally impaired patients because the way it works is it's a diuretic. So these people will urinate out a lot. So you do have to be cognizant that you're going to need to volume replete them. And we talked about some anesthetics and analgesia, but I want to mention that propofol and benzodiazepines, the reason why they're beneficial for intracranial pressure is they really decrease the metabolic demand of the brain. So if you think there's a pain component to it, analgesia is going to help, but that isn't going to work in the same way that propofol and benzodiazepines are. So for her, unfortunately, her ICP was still elevated after we started these hyperosmolar therapies, increased her sedation. So what can we do for her additionally? Well, you can do CSF diversion, cerebral spinal fluid. And some people say, well, why didn't you just put an EBD, an external ventricular drain in to begin with? Why start with a bolt? And the reason is there was a meta-analysis in 2024 in the Journal of Neurocritical Care that didn't really show much difference in mortality. If you had an intracranial monitor or intracranial monitor, which they're going to abbreviate IPM versus an EBD. And people who could get away with just having an IPM, they had a shorter duration of ICU stay, shorter duration overall of the need for an intraparenchymal monitor, again, which is going to require you to be in an ICU. So if we don't have to use an EBD, you know, you don't want to. The other thing with EBDs are you are in the CSF space. And a lot of times you are going to, you potentially can manipulate that. And so that is an introduction for infection risk. So, but again, when you have high pressure in the skull, what can you do to kind of decrease pressure? You can decrease things that are in the skull. And one of that is fluid. So for her, she got an EBD. This is the EBD going into the third ventricle here. And we actually left the bolt in. So this is the EBD here and the bolt as well. Because if at some point she didn't really need the EBD for CSF drainage, we could always take that out to, again, lower the infection risk and just continue to do intracranial pressure monitoring with the bolt alone. For her, unfortunately, even with that, she still had high ICPs. So this is an algorithm that most people will kind of go down the line. Some of these are used in concert in how to treat elevated ICP. So for her, we've done the anesthetics and analgesia, the hyperosmolar therapy, CSF diversion. So what's next? Paralytics. You have to remember, in these patients, intracranial pressure can be influenced by increased pressure in your chest cavity and in your abdominal cavity. So we usually use paralytics to kind of take the chest out of the picture. So there's no movement, really, of the diaphragm other than what the ventilator is doing it. And you want to have your ventilator on lowest PEEP possible, you know, obviously, bearing that the patient may have other injuries or things like that, ARDS from lung contusions, but doing the minimal PEEP as possible because that can elevate your intracranial pressure. Hypothermia. This is usually a graded. You start with maybe 35 to 36 degrees. Hypothermia has its own challenges, as people know, with, you know, coagulopathies, if you do it rapidly, you can have changes in electrolytes, acidemia as well. And then really kind of one of our last line defense is a pentobarb coma. I think, you know, just in my clinical experience, I probably have only put a person in pentobarb coma like two or three times in my career. And the goal of this is really to decrease any metabolic demand from the brain and you titrate it to kind of burst suppression on an EEG. So you have to have an EEG on when you're doing this. And people get all sorts of complications such as acidemia, you get ileus, you're at a higher infection risk because you're not really moving your muscles, clot burden for same reason. So it's definitely a last ditch resort. And then a question we get a lot, which is a good question is, well, if globally your pressure in your brain is high, what about just taking the skull off on both sides? And so they've actually looked at that. There have been a couple of trials, the most recent being called the RESQ-ICP trial. And really there was no difference between groups for a good recovery or moderate disability. However, I mean, you do see lower rates of mortality if you do it, but higher rates of severe disability and vegetative state. So really what this does is it keeps a person alive, but it doesn't really improve their outcomes. So most of the time you're not gonna see any neurosurgeons offer this or any neurocritical care physicians offer this. I just wanna say now I have, so my patient underwent all of those except for the decompressive craniotomy. And six months later, she was walking, talking, back to school and had a great outcome. So this is why we do all these things for these patients because they can come in and they can look really bad, have a terrible neurologic exam, have a lot of complications. We didn't even talk about some of the complications you can get throughout the course. That's for the next series or lecture in the series that Dr. Capucci will talk about, but they can have good outcomes, especially the younger people because their brains are still very plastic. And so they can really undergo this degree of injury and bounce back. So there's a reason why we do all of this. And then I have some miscellaneous guidelines that didn't really fit into a specific case. Depressed skull fractures is another thing that we see often. The fracture I showed you in the first case, that was non-displaced, meaning the skull didn't move in or out. And people will generally operate on skull fractures while it's recommended by the Brain Trauma Foundation. If the depressed, excuse me, if the fracture or the depression is greater than the thickness of the skull. And so really what that means is if you have a skull in continuum like this, and say that this is the outside world, and then this is the brain here, and you have this piece, it has to be, the shift has to be the whole thickness of the skull. So if you have just the halfway, that's probably gonna mend and not gonna be a problem. But if it's at least the thickness of the skull, that can be problematic because you can have cerebral spinal fluid leak and it's an infection risk. And the other times is if there's involvement with the frontal sinus, there's visible like wound infection, contamination, or if there's a large degree of pneumocephalus, meaning error in the brain, that can become problematic. And the other thing that we get is about antibiotics. And there was actually some guidelines that came out in 2024 by the AAST Critical Care Committee. For any penetrating brain injuries, so stab wounds, gunshot wounds, they recommend cefazolin or ANSEF for three days. Open or contaminated facial fractures usually can do just 24 hours of ANSEF. And then with a consideration of using ceftriaxone or ampicillin, sulbactam in addition to that. There's many other like nuances to that, but it's all outlined in that AAST Critical Care Committee guideline paper. For non-operative facial fractures, for people who just need some nasal packing, and even if you have a CSF leak, they do not recommend systemic antibiotics. Sometimes our ENT colleagues, if there is a CSF leak from the ear, they'll recommend like otic drops, antibiotic drops, but not systemic antibiotics. And that really concludes most of what I think about for a patient when I'm taking care of them in the first 48 hours from when they come in to the ED to getting them upstairs in the ICU and monitoring them closely. I did make a cheat sheet for anybody who wanted to screenshot this or save it for later. This kind of has just some of the initial management guidelines that we talked about. You know, SBP, the 100 to 150, again, that 100 being a little bit patient age dependent if you want to go with a class three recommendation, but most of the time, this is what we're going to go with. And again, the 140, if they're an operative candidate. Yes, we'd like to reverse anticoagulation if you're on it. TXA for mild to moderate TBIs within the three hours. Don't transfuse platelets unless you're going to the OR. And using Keppra one gram followed by 500 to a thousand milligrams twice a day for seven days. Repeating your brain imaging and obtaining vessel imaging. These are all the guidelines for when you should operate. And I'll just give the additional, you know, caveat too, that these are when you should operate. That doesn't mean that if you don't meet all of these requirements, they're not, they're necessarily not an operative candidate. Again, this is going to be a discussion with the neurosurgeon, the neurocritical care team involved depending on the patient. The pupillary measurements, the antibiotic management, and then sort of our algorithm that we go down for the management of elevated intracranial pressure. Hope that this was helpful. Feel free to reach out to me at any time if you have questions. My email is lina.okeefe at yale.edu. Hope you found this great, informative. Thank you very much, Dr. O'Keefe. I thought it was informative. It's just a testimony that you never stop learning. Thank you very much for the amazing information. Love the cheat sheet at the end. I'm sure that is going to be captured a lot. I do have some questions for you. Absolutely. Classic teaching is that epidural hematomas can present with that lucid interval and then they decline neurologically. Do you ever operate on them before they get worse? Great question. The answer is yes. It's not a definitive no. I think for some of those higher risk patients, if you're younger, and the reason why younger is really meaning that your brain is fuller. If it's in the temporal lobe, like we talked about, you're at higher risk of earlier herniation. And again, if like your exam is kind of borderline when you come in, maybe you're lucid, but maybe you do have that pupillary dilation on that side, if you're on anticoagulation. So some people will take them. Again, this is gonna be on a case by case basis, but I think if you're higher risk for decompensation, sometimes the surgeons will just take them because if you wait till someone herniates, that's obviously harder to come back from than a surgery ahead of time. That being said, there's obviously lots of risks with having a surgery, infection, bleeding, all of that. So I'm not a neurosurgeon, so I don't wanna speak on behalf of them, but yes, I have definitely seen people who take people before they meet the full criteria. Fantastic, thank you. Something that just sort of caught my attention, pupillary assessments are so important with TBI patients. So in that patient with really severe facial trauma, do you alter your threshold for intervention if you can assess their pupillary responses? That is a great question. So people with facial trauma definitely can have abnormal pupillary measurements. We see this all the time. So say you have an injury that's coming more to, I don't know, I'm making it up, the right side, and so you have a lot of orbital fractures, and so the pupillary dilation is because of that. If you have a neurologic exam that you can follow, they're awake, and you can really do a good assessment on them, that's gonna be your surrogate more so than the, I mean, the pupil is not significant at this point. It doesn't tell you any information. If they don't, if they have a poor exam, you might rely a little bit more on your other testing. So you're gonna might be getting, so say they have like a subdural or an epidural right in that same area that can become problematic where you don't necessarily know if it's problematic. Again, I think that's part of the reason why they came up with these guidelines of when to operate definitively. But if you don't meet some of that criteria, you might be getting CT scans more frequently. They might be a candidate for putting an intracranial monitor in so that you can sort of assess them that way. Perfect. So you just made me think of something else. So how did the neurointensivist work with the neurosurgery team? You're both experts, you have a different focus. So how do you balance that management? Yeah, that's a really good question. I think the surgeons usually have a pretty clear role of operate, not operate. And they have some of these hard rules that they can go by. And then we really are the ones who are at the bedside more frequently. We're with our nurses, we're in the unit watching these neuro exams as they transpire over days. And we're the ones who are saying, hey, this person is starting to maybe deteriorate. We might need to think about surgery. Or we're the ones who are kind of like prepping them. Maybe this is the indication you take them to surgery where you don't meet all the criteria. And so then we have like a discussion and everyone has their own experiences to rely on. Like, oh, the last time I took a patient like this to the OR, they ended up having this complication. You know, and we kind of discuss all the risk benefits and whether or not we think a patient who doesn't meet hard criteria based on these guidelines of whether or not they should either go to the OR or if they should get an intracranial monitor. Perfect, so along that line about discussion and management, I know that this is something that my trauma team talks about a lot. But when you're talking about VTE prophylaxis in the TBI patient, especially if they have hemorrhages, can you offer some thoughts on heparin versus enoxaparin? Great question. Most of the time for TBIs, you're going to do heparin. I don't think there is great, but there is not great literature to say one way or another, heparin versus enoxaparin. I think for whatever reason, a lot of spinal cord injury, they prefer enoxaparin. And to be honest, I'm not 100% familiar with all the literature behind that. But for intracranial hemorrhage, there isn't really much of a difference between what you use. The heparin sub-Q, you do give a little more frequently, meaning that usually that means that it's not in your system as long. And so maybe it could be reversed a little bit faster if they do have a change. But there's a great guidelines on the Neurocritical Care Society page that says like kind of reversal for all the anticoagulation for any type of intracranial hemorrhage, if you guys want to reference that. But that's where that comes from. And what I'm saying is like, it doesn't really matter which kind of VT prophylaxis you're on, I haven't really seen a difference. Okay, thank you. Appreciate that. Specifically when considering the results of the CRASH-3 study, for those centers, smaller centers that need to send patients with these kinds of injuries to a higher level of care, what are your recommendations on giving TXA? Especially, you spoke of that three hour window. What would you say to a smaller center? Yeah, I think if they have someone who is in that realm of mild to moderate TBI, I would give it. Give at least that first gram because we didn't really see any harm to it. So yeah, I would recommend giving it, especially if you think that is a person kind of like the epidural that we talked about who could become high risk and needing surgery and things like that. So I would recommend giving it. Perfect, perfect. Thank you. Just, I believe it was regarding that case you just referenced. For C collars, if patients have C collars on, do you, what are your thoughts on that when you're talking about keeping the neck straight and optimizing venous return? Are they helpful? Do we need to be careful with the way they're placed? Does the kind of collar matter? I, you know, that's a good question. I was thinking about that as I was talking. Most of the time, it does not impede venous drainage because in fact, it helps keep your neck in line. If it's a malfitting collar, then it can become problematic. So you really want to make sure you have the collar is appropriately sized to your patient. Because if it's like too small, then it, you know, you can get some compression on the internal jugular veins. I mean, just a little bit of pressure can occlude enough that you're getting some backlog there. If they're too big, then you can still move around in them. And then they're not really that helpful either, or they could be compressing, honestly, in the IJ up underneath the jaw, like here. So really it's more about making sure the collar fits correctly. And there's no like really bad pressure points on the neck. Great tips. So now you've been speaking about the first 48 hours of management. So what kind of considerations in that timeframe do you have for like mobilization, NPO status, nutrition, that kind of thing? I'm a big proponent of nutrition. I think as soon as you can give nutrition, you should, because people can run into complications. They can run in like alias and things like that, where you're gonna have interruptions in nutrition. And nutrition is very helpful for recovery. You're gonna have a lot of insensible losses throughout people's courses. And you're gonna really need that protein and things like that to keep your healing going. And it's gonna be interrupted. Like if they're gonna have procedures, they're gonna go for scans. All during those times, you're gonna have interruptions in your nutrition. So I'm a big proponent of nutrition. And then, sorry, what was the second part of your question? Mobilization. Mobilization. I think if you have an exam that you can work with, you should mobilize them. So, because then they, and really the mobilization is gonna come from, I'm gonna say this, in the absence of like a C-spine injury. C-spine injury is different. If you're really concerned about that, then you're gonna have your either C-spine precautions or total spine precautions, depending on the patient. But someone who does not have evidence of that, move them. Please move them. Even if they're comatose, do passive range of motion. That helps with the things like DTIs and helps with getting those muscles, pumping blood back to the heart. So you're preventing DVTs, helping open up those lungs and things like that. So for getting all of those other complications down the line of infections and blood clots. And you don't want people wasting away. You don't want them to have become atrophic and then develop critical illness myopathies and polyneuropathies, but then they have to work to get over that hump as well. So yeah, mobilization for sure. Fantastic. Well, I think I have exhausted my question list for you. I think they were great questions. Well, thank you. I wanna thank you very much. Like I said, I've learned a lot from this. I think that this is some great information that our audience will definitely appreciate and we'll be able to use in patient care. So I wanna thank you very much, Dr. O'Keefe, for providing us with this information today. And I wanna thank our audience for joining us. And if you have nothing else to say, I think we can close for today. Great, thank you everyone. Thanks everybody.

traumatic brain injury

Dr. Lena O'Keefe

initial assessment

Brain Trauma Foundation

epidural hematomas

intracranial pressure

anti-seizure medications

Tranexamic Acid

neuroprotection strategies

neurosurgical collaboration