General Management Considerations for MWDs with TBI
It is critical to ensure adequate resuscitation and management of cardiovascular and respiratory problems, as hypotension, poor tissue perfusion, and hypoxia lead to progressive brain injury due to the adverse effects of secondary neurological injury due to ischemia, cerebral edema, reperfusion injury, and so forth. (See Figure 48.)
- Follow guidance in this CPG for management of shock, hypotension, hypovolemia, hemorrhage control, and respiratory dysfunction.
- Be prepared to intubate patients that are not breathing or have depressed ventilation; careful intubation using manual in-line stabilization (MILS) is essential to minimize further injury.
- Focus care on preventing hypoxemia, maintaining cerebral perfusion pressure and systemic arterial pressure in the normal ranges, and preventing secondary ischemic cerebral injury.
- Provide 100% oxygen by facemask. Monitor respiratory rate and effort. Be prepared to intubate and provide supplemental oxygen by ET tube. Maintain arterial carbon dioxide content in the normal range using assisted manual ventilation. Avoid hyperventilation!
- Maintain normotension (MAP 70-80 mmHg or systolic BP >90 mmHg). Start IV crystalloid fluid therapy to correct shock and provide ongoing volume support (See CPG 6, Figure 33). Measure blood pressure if possible; otherwise, guide fluid therapy based on presence or absence of distal pulses. Consider hypertonic saline (4 mL/kg IV over 5 min) or hyperoncotic fluid (HES, 10 mL/kg IV) boluses if hypotension persists despite crystalloid use.
- Nurse with head elevated 300 with neutral neck position, avoid external jugular vein compression and catheters, avoid procedures that stimulate coughing or sneezing.
- If evacuation will be prolonged and the patient is recumbent, rotate lateral recumbency and lubricate the eyes with ophthalmic ointment every 4 hours and maintain in a well-padded area.
- If the MWD is conscious, restrict activity and movement (e.g., portable kennel), which may require sedation and analgesia (See CPG 16).
- Give mannitol, 1.5 grams/kg, IV, over 30 min for MWDs with a MVGCS score of ≤ 8. Repeat this dose once more 4-6 hours after the first dose. Note that dogs are less likely to suffer subdural or intracranial hemorrhage; thus, mannitol should be used early in any MWD with moderate-to-severe TBI (MVGCS ≤ 8).
- Do NOT use corticosteroids to treat MWDs with TBI.
Figure 48. Management Algorithm for TBI for MWDs