Why is RSI important in a presumed large intracranial bleed (with a low GCS)?
Airway protection
These patient’s airways are threatened and therefore they are at high risk of obstructing and/or aspirating.
Neuroprotection
A key principle in managing a patient with a presumed brain bleed is avoidance of secondary brain injury.
Hypercapnia, hypoxia, hypotension, impaired cerebral venous return and uncontrolled seizure activity must all be avoided for this purpose.
A guiding principle in neuroprotection is to intubate, and then “make everything normal” (i.e. normoxia, normocapnia, normotension, normothermia). More below.
Intubation/mechanical ventilation is the only way to tightly control pCO2 - a key determinant of cerebral blood flow. Hypercapnia causes cerebral vasodilation which increases the blood volume in the skull... and raises ICP in the patient with a large intracranial bleed.
Safe, neuroprotective RSI in the brain injured patient deserves to be an entirely separate blog post (which I’ll do one day!).
Key things to remember when it comes to neuroprotection of the intubated patient with an intracranial bleed
If possible, tape the ETT to the face as opposed to using a tube tie. This reduces the risk of impaired cerebral venous return (by compressing the jugular veins). In other words, the brain can drain.
Mechanically ventilate to low-normal normocapnia (pCO2 of approx 4.5KPa).
Maintain SpO2 >95% (but don’t over-oxygenate, titrate down if needed).
Avoid high PEEP (impairs venous return).
Aim for SBP >110. Hypotension is catastrophic in brain injured patients. Use fluids and vasopressors where needed.
Maintain a suficient level of sedation, analgesia, and neuromuscular blockade to prevent further seizures, or coughing on the ETT/becoming agitated.
Consider a loading dose of IV Keppra if any suggestion of seizure activity.
Keep the bed tilted to maintain the patient at 30 degrees head up position.
Correct hypo/hyperglycaemia.
Aim for normothermia.
Hypertonic saline
If there are signs of raised ICP, administer hypertonic. Our local guidelines suggest 6ml/kg 5% hypertonic saline (max dose 350ml).
This is a temporising measure to slow progression and prevent brain herniation. It might buy time to get them to definitive care (neurosurgery).
The response(s) you are looking for:
Correction of Cushing’s reflex (hypertension, bradycardia, irregular respiratory pattern).
Normalisation of unilateral/bilateral fixed pupils.
Hypertonic saline can be administered a second time if there is no response to the first bolus.
What is a “Code Black”?
This is a type of trauma call that gets put out at the Royal London (our local MTC).
It is specific to the TBI patient with a possible time-critical brain bleed.
The purpose of a Code Black is to mobilise the correct resources to rapidly facilitate neurosurgery (decompression of an intracranial haemorrhage with mass effect). This includes a neurosurgical team who attend the trauma call in resus, and readying theatres to receive the patient straight from the CT scanner.
Criteria for a Code Black (all must be present):
The patient is (or requires) intubation and the pre-intubation GCS is ≤8.
There is a clinical suspicion of significant head injury.
There are pupillary changes (unilateral or bilateral fixed dilated pupils) suggesting impending herniation.
A Code Black can also be put out if a CT head shows an acute bleed with mass effect, even if the above criteria are not met.
At my place (not an MTC) we don’t have a SOP for the Code Black-type patients that arrive (and therefore need rapid transfer out). Perhaps we should…
Cheers all,
Robbie
@robbielloyd.bsky.social
Great summary, so many pearls. I prefer to tie the tube above the ears for neuro protection- can be tricky using tape - sweat, blood,vomit, facial hair ect and risk of dislodgment with multiple moves then it gets taped once settled into ICU or OT.