Initial management

Initial management of TBI

Primary survey with simultaneous resuscitation

Airway and breathing with cervical spine protection

Optimize oxygenation and ventilation with use of adjuncts or intubation if necessary
Prevent hypoxia and treat pneumothorax if present
Immobilize the cervical spine where required

Circulation with haemorrhage control

Avoid/treat hypotension with use of intravenous fluids
Look for source of haemorrhage if unexplained hypotension

Disability

Assessment of GCS and pupil size/reactivity
Mannitol or hypertonic saline if unilateral pupillary dilatation
Blood sugar measurement with avoidance of hypoglycaemia

Exposure

Identify any obvious and/or serious extracranial injuries

Definite or suggestive history of head injury?

Focused assessment

Focused neurological examination

Looking for focal neurological deficits including cranial nerve abnormalities

Focused assessment of the head and neck region

Observe for signs of trauma, including skull fracture or CSF leak

AMPLE history with additional relevant questions

Allergies, medications, past medical history/pregnancy, last meal, events leading to trauma/mechanism of injury, loss of consciousness, seizures, vomiting, retrograde amnesia

CT head +/- cervical spine +/- rest of body

Imaging chosen depends on above findings, mechanism of injury, and local guidelines

Management dependent on imaging findings

Acute mass lesion

Discussion with neurosurgical team regarding neurosurgical intervention

Severe TBI (GCS 8 or below)

Discussion with neurosurgical centre and likely admission to neurointensive care

Moderate TBI (GCS 9–12)

Discussion with neurosurgical centre regarding need for transfer to neurosurgical unit or neurointensive care

Mild TBI (GCS 13–14)

Usually managed through observation in normal ward setting

Aim

Prevention or immediate correction of

Hypoxaemia
Hypotension

Rapid diagnosis and evacuation of an expanding intracranial haematoma treatment of raised ICP

Unless the patient is alert and cooperative, the cervical spine should be immobilized while awaiting imaging and/ or formal clinical assessment.

Life- threatening extracranial injuries should be stabilized prior to transfer.

Indication for ICU admission

Severe traumatic brain injury (defined as a post-resuscitation Glasgow Coma Scale score ≤8)

Clinical or radiological evidence of raised intracranial pressure

Need for mechanical ventilation due to:

Decreased conscious level
Evidence of brainstem dysfunction
Acute respiratory failure (e.g. due to neurogenic pulmonary oedema)
Episodes of apnoea
Generalized tonic-clonic seizures or status epilepticus
Any other cause of a compromised or threatened airway

Cardiovascular instability requiring intensive haemodynamic monitoring and management

Need for invasive neurological and systemic monitoring

Management of systemic organ support such as renal and cardiac dysfunction

Postoperatively following neurosurgical interventions

Multisystem trauma

Critical care management of severe head injury

Category	Management Details
Ventilation	- PaO₂ >11 kPa - PaCO₂ 4.5–5.0 kPa - Lung protective ventilation strategies (tidal volume 6 ml/kg ideal body weight, PEEP 6–12 mmHg and recruitment manoeuvres) as brain-directed therapy allows - PEEP to maintain oxygenation (PEEP ≤12–15 cm H₂O does not have adverse effects on ICP and may reduce ICP if oxygenation is improved) - Ventilator ‘care bundle’ to minimize risk of pneumonia: – Head-up positioning – Oral hygiene – Peptic ulcer prophylaxis – Venous thromboembolism prophylaxis – Daily sedation holds if ICP allows
Cardiovascular	- MAP > 90 mmHg - Target euvolaemia with isotonic crystalloids - Vasopressors/inotropes if insufficient response to fluid
ICP and CPP targets	- CPP 60–70 mmHg - ICP <22 mmHg
Other	- Normoglycaemia - Normothermia - Seizure control - Enteral nutrition - Thromboembolic prophylaxis

NICE

Referring to neurosurgery

Anyone with new and surgically significant abnormalities on imaging.

The definition of 'surgically significant' should be developed by local neurosurgical centres and agreed with referring hospitals, along with referral procedures.

Regardless of imaging, discuss a person's care plan with a neurosurgeon if they have:

Persisting coma (a GCS score of 8 or less) after initial resuscitation
Unexplained confusion that persists for more than 4 hours
Deterioration in GCS score after admission (pay more attention to motor response deterioration)
Progressive focal neurological signs
A seizure without full recovery
A definite or suspected penetrating injury
A CSF leak.

Transfer to neurosurgical unit

Above 16

Transfer would benefit anyone with serious head injuries (a GCS score of 8 or less), irrespective of the need for neurosurgery

Do not transfer them to a service that is unable to deal with other aspects of trauma

Complete the initial resuscitation and stabilisation of the person, and establish comprehensive monitoring before transfer, to avoid complications during the journey. Do not transport someone with persistent hypotension, despite resuscitation, until the cause has been identified and they are stabilised

Intubate and ventilate

Any patient needing transfer to NSx unit

GCS score of 8
Significantly deteriorating conscious level (1 or more points on the motor score), even if not coma
Unstable fractures of the facial skeleton
Copious bleeding into the mouth (for example, from a skull base fracture)
Seizures.

Any patient

Coma, that is, they are not obeying commands, not speaking and not eye opening (a GCS score of 8 or less)
Loss of protective laryngeal reflexes
Ventilatory insufficiency, as judged by blood gases: hypoxaemia (PaO2 less than 13 kPa on oxygen) or hypercarbia (PaCO2 more than 6 kPa)
Irregular respirations.

Anyone whose trachea is intubated should have appropriate sedation and analgesia along with a neuromuscular blocking drug.

Aim for a PaO2 of more than 13 kPa, and a PaCO2 of 4.5 kPa to 5.0 kPa, unless there is clinical or radiological evidence of raised intracranial pressure, in which case more aggressive hyperventilation is justified.

If hyperventilation is used, increase the inspired oxygen concentration.

Maintain the mean arterial pressure at 80 mmHg or more by infusion of fluid and vasopressors, as indicated.

Below 16

Similar to above

Providing that the paediatric modification of the GCS is used for preverbal and non-verbal children. Ventilate people under 16 according to the age-appropriate level of oxygen saturation and maintain blood pressure at a level appropriate for their age.

NICE:

Hospital admission criteria after head injury:

New, clinically important abnormalities on imaging

(An isolated simple linear non-displaced skull fracture is unlikely to be a clinically important abnormality unless they are taking anticoagulant or antiplatelet medication)

After imaging, a GCS score that has not returned to 15 or their pre-injury baseline, regardless of the imaging results

When there are indications for CT scanning but this cannot be done within the appropriate time period, either because CT is not available or because the person is not sufficiently cooperative to allow scanning

Continuing worrying symptoms (for example, persistent vomiting, severe headaches or seizures) of concern to the clinician

Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak, or suspicion of ongoing post-traumatic amnesia).

See the section on discharge and follow up for recommendations about other factors to consider, such as whether supervision at home is available.

Observation of people who has been admitted

Minimum acceptable documented neurological observations are:

GCS score,
Pupil size and reactivity,
Limb movements,
Respiratory rate,
Heart rate,
Blood pressure,
Temperature
Blood oxygen saturation.

Observation frequency

Carry out and record observations on a half-hourly basis until there is a GCS score of 15.
Observations for people with a GCS score of 15 should start after the initial assessment in the emergency department and the minimum frequency should be:

Half-hourly for 2 hours, then
1 hourly for 4 hours, then
2 hourly.

Revert to half-hourly observations and follow the original frequency schedule for people with a GCS score of 15 who deteriorate at any time after the initial 2‑hour period.

If patient deteriorates

Urgently reassess a person with a head injury if they have any of these signs of neurological deterioration:

Agitation or abnormal behaviour
A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (give more weight to a drop of 1 point in the motor response score of the GCS score)
Any drop of 3 or more points in the eye opening or verbal response scores of the GCS score, or 2 or more points in the motor response score
Severe or increasing headache, or persistent vomiting
New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.

To reduce interobserver variability and unnecessary referrals, get a second member of staff competent in observations to confirm deterioration before involving the supervising doctor
Perform a CT immediately and reassess patient

AAGBI transfer guidelines

Nathanson 2019.pdf

1.4 MiB

Unsorted

Primary brain injury

Diffuse axonal injury

Damage occurs at node of ranvier

Contusion formation

Cranial trauma

Keep systolic around 100mmHg
There isn’t difference in onset time between mannitol and hypertonic saline
Give 7 days of keppra post head injury

Esp if worried of seizure that can worsen outcome

1/2 hrly neuro obs until gcs 15
Coagulation and haemostatsis
LMWH: if leave for 6 hrs will be out of system (half life 4 hrs)
Rotem: point of care testing has tracing that can be used to figure out
ICP waveform: P1 P2 and P3

Brain trauma foundation guidelines-brain trauma.org

Craniectomy saves more life but causes more disability
If you want to do a frontotemporopareital Decompression do a large one at least 12x15x15cm and not a small one.
Prophylactic hypothermia is not recommended

Polar studies
Euroterm trial

Hyperosmolar therapy

Can lower intracranial pressure
No difference between hypertonic saline vs mannitol
Must avoid arterial hypotension (Systolic <90mmHg)

CSF drainage

EVD zeroed at midbrain with continuous drainage of CSF more effective than intermittent drainage
Use of CSF drainage to lower ICP in patients with an initial GCS of< 6 in the first 12 hrs may be considered

Hyperventilation

Do not have prolonged hyperventilation with pp of CO2 <25 mmhg

Anaesthetics and analgesics and sedatives

High dose barbiturates is recommended to control elevated ICP refractory to standard medical and surgical treatment
Propofol is recommended for the control of ICP, it is not recommended for improvement in mortality or 6 months outcome

Steroids

Do not use as high does methylpred was associated with greater mortality

Nutrition

Feed patients to attain basic caloric replacement at least by 5th day and at most by 7th day is recommended to decrease mortality
Transgastric jejunal feed is better than NG feed because it reduces incidence of ventilator associated pneumonia

Infection prophylaxis

Early tracheostomy is recommended to reduce mechanical ventilation days but has not shown to reduce mortality or rate of pneumonia
Do not use providing-iodine oral care to reduce VAP as it increases risk of ARDS
Use antimicrobial impregnated catheters to reduce EVD infection

LMWH an heparin has increased risk of intracranial haemorrhage expansion

Give when the brain injury is stable → do CT head ?

Seizure prophylaxis

Use keppra 7 days if worried
But no evidence for it
All evidence is for phenytoin or valproate but both been show to not reduce late post traumatic seizures
Phenytoin is connected to decrease the incidence of early PTS (within 7 days of injury), however early PTS has not been associated with worse outcomes

Intracranial pressure monitoring

Management of severe TBI using ICP monitoring is recommended to reduce in hospital and 2 week post injury mortality

CPP monitoring

CPP monitoring decreases 2 week mortality

Jugular bulb monitoring of Arteriovenous oxygen content difference (AVDO2) may be considered to redefine mortality and improve outcomes at 3 And 6 months post injury
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 over 70 years old may be considered to decrease mortality and improve outcomes.
ICP >22mmHg should be treated to reduce mortality (above 22mmHg shown to have increased mortality)
Keep CPP between 60-70mmhg, do not increase CCP > 70mmHg with fluid and pressers as it increases risk of adult respiratory failure
Jugular venous saturation of < 50% may be a threshold to avoid in order to reduce mortality and improve outcomes

Treat ICP above 22, because above 22 increased mortality

Transalar herniation

Same as sphenoidal herniation
Can be ascending and descending

Ascending

To detect glutamate LDH etc in head injury
Due to frontal lobe swelling

Descending

Due to temporal lobe swelling