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   Table of Contents      
LETTER TO THE EDITOR
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 72-73

Being ‘Mr Sensible’ while caring for severe traumatic brain injury (TBI) patients in ICU


PGIMER, Chandigarh, India

Date of Submission04-Feb-2020
Date of Decision26-Feb-2020
Date of Acceptance26-Mar-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
senior resident Summit Dev Bloria
c/o 3245/15d Chandigarh 160012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_8_20

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How to cite this article:
Bloria SD. Being ‘Mr Sensible’ while caring for severe traumatic brain injury (TBI) patients in ICU. MAMC J Med Sci 2020;6:72-3

How to cite this URL:
Bloria SD. Being ‘Mr Sensible’ while caring for severe traumatic brain injury (TBI) patients in ICU. MAMC J Med Sci [serial online] 2020 [cited 2020 May 31];6:72-3. Available from: http://www.mamcjms.in/text.asp?2020/6/1/72/283512



Sir,

Traumatic brain injury (TBI) accounts for around 50% of all trauma deaths.[1] Intensive care unit (ICU) care of these patients can be quite extensive with many specific considerations. For those not caring for these patients regularly, there is a possibility of forgetting one or more of these considerations and hence may lead to substandard care. We present ‘Mr SENSIBLE’ as a mnemonic to guide ICU care of these patients. This is akin to the use of other mnemonics used in ICU and anaesthesia like FASTHUG, LEMON etc. While the mnemonic may act as a memorizing tool, it is by no means extensive and definitely not to be used without considering the clinical condition of the patient. Most of these considerations have been taken from the recent brain trauma foundation (BTF) guidelines.[2]


  M − Mannitol administration Top


Mannitol is an osmotic diuretic that decreases intracranial pressure (ICP) in a dose of 0.25–1 gm/kg. When used without ICP monitoring, it should be used only in patients with progressive neurological deterioration or signs of impending herniation.


  R − Respiratory management Top


Hyperventilation is not recommended in first 24 hours post injury. Post 24 hours, hyperventilation should be used only as a temporizing measure for ICP reduction.


  S − a) Straight head up without any neck rotation Top


b) Sedation

  1. These patients should be kept 30° head up to assist venous drainage from brain. Also, excessive neck rotation/tilting should be avoided to prevent impaired cerebral venous outflow and hence raised intracranial pressure.
  2. Appropriate sedation should be provided to these patients as pain and agitation can increase ICP. However oversedation should be avoided as it can interfere with neurological examination.



  E − ’Epilepsy’ prophylaxis Top


Post - TBI, administration of antiepileptics is recommended for prevention of early post-traumatic seizures. Phenytoin remains the most commonly used drug for the purpose, with a loading iv dose of 15 mg/kg followed by 100 mg tds for adult patients.

Levetiracetam can be used as antiseizure drug in place of Phenytoin.


  N − a) No nasogastric or nasotracheal tube Top


b) Nutrition

  1. TBI patients having skull base fractures should not be inserted any nasogastric/nasotracheal tube as it might make bacteria and other material to reach brain.[3]
  2. Also, feeding should be started in these patients as early as possible and the basic caloric replacement should be attained by the fifth day.



  S − Suction prophylaxis Top


In addition to the usual suction prophylaxis, it is recommended to administer drugs like lidocaine (1.5 mg/kg) or barbiturates prior to suctioning as endotracheal suctioning can cause increase in intracranial pressure.[4]


  I − a) Intracranial pressure monitoring Top


b) Infection prophylaxis

  1. As per BTF guidelines, ICP should be monitored in all patients with a TBI (GCS 3-8 after resuscitation) and an abnormal computerized tomography (CT) scan. ICP monitoring is indicated in patients with severe TBI with a normal CT scan if any 2 of the following features are noted at admission: age >40 years, unilateral or bilateral motor posturing, or systolic blood pressure <90 mm Hg. ICP constantly over 22 mm Hg is associated with poor outcome and should be treated. ICP monitoring in these patients leads to lower in-hospital and 2 week post injury mortality.
  2. Early tracheostomy has been shown to reduce the duration of mechanical ventilation in these patients.



  B − Beat to beat blood pressure monitoring Top


Continous blood pressure monitoring is recommended as even a single episode of hypotension is said to double the mortality in severe TBI patients.[5] The BTF recommendations suggest maintaining SBP at >100 mm Hg for patients 50 to 69 years old or at > 110 mm Hg or above for patients 15 to 49 or >70 years old. Rapid administration of Mannitol and Eptoin can lead to hypotension and should be avoided.


  L − Lower limb pneumatic compression devices Top


These patients are at risk of development of deep vein thrombosis and it is recommended that these patients be provided with compression stockings during their stay in ICU.


  E − Evaluation of neurological status regularly Top


Regular neurological examination is necessary in these patients to diagnose any deterioration in Glasgow coma scale. Sedation should be stopped prior to neurological examination (sedation holiday).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shackford SR, Mackersie RC, Holbrook TL et al. The epidemiology of traumatic death. A population-based analysis. Archives of Surgery 1993;128:571-575.  Back to cited text no. 1
    
2.
Carney N, Totten AM, O’Reilly C et al. Guidelines for the management of severe traumatic brain injury.4th ed. Neurosurgery 2017;80:6-15  Back to cited text no. 2
    
3.
Seebacher J, Nozik D, Mathieu A. Inadvertent intracranial introductionof a nasogastric tube, a complication of severe maxillofacial trauma. Anesthesiology 1975;42:100-2.  Back to cited text no. 3
    
4.
Bedford RF, Persing JA, Pobereskin L et al. Lidocaine or thiopental for rapid control of intracranial hypertension? Anesth Analg 1980;59:435-7.  Back to cited text no. 4
    
5.
Chesnut RM, Marshall LF, Klauber MR et al. The role of secondary brain injury in determining outcome from severe head injury. The Journal of Trauma 1993;34:216-22.  Back to cited text no. 5
    




 

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