Traumatic brain injury

ASSESSMENTMANAGEMENTOF HEAD INJURY

ASSESSMENT

ACUTE MANAGEMENT

Resuscitation

BTLS/ATLS APLS

A

B

C

IRWAY

REATHING

IRCULATION

A IR WAY

Maintain SPO2 > 90% Maintain PaO2 > 60mmHg

When do you intubate?

Indication for intubation

Unable to maintain airway

GCS ≤ 8Loss of protective laryngeal reflexesUnstable facial bone # Bleeding into mouthSeizures

Ventilatory insufficiency Spontaneous hyperventilationIrregular respiration

B REATHING

Maintain PCO2 35-40mmHgObtain CXR ASAP

Check ABG

C IRCULATION

Prevent hypotension Aim SBP> 90mmHg

Resuscitation with isotonic cystalloid Inotropes (adrenalin) if needed

Normal

Hypotension

Hypotension+ Hypoxia

Mortality rate

Traumatic Coma Data Bank study

2 x2.5 x

NEUROLOGICALASSESSMENT

Opens their eyes when you say their name, and speaks to you in words that

make no sense. When you apply pressure on their nail bed, they move

their arm away.

10 - M4 V3 E3

Moves hand towards head when you apply pressure above the eye socket. They are

disoriented but able to form sentences. They open their eyes in response to speech.

12 - M5 V4 E3

Spontaneously looks around. When you speak to the patient, they can tell you who they are, where they are and why, and the

date, and obey simple commands.

15 - M6 V5 E4

Adult, can obey simple commands and opens their eyes when they hear you speak. They

can talk to you in sentences and seem a little confused and unsure of where they are.

13 - M6 V4 E3

Indications For Referral to

HOSPITAL

•GCS<15 at initial assessment for two hours and refer if GCS score remains<15 after this time)• post-traumatic seizure (generalised or focal)�• focal neurological signs�• signs of a skull fracture (including cerebrospinal fluid from nose or �ears,haemotympanum, boggy haematoma, post auricular or periorbital bruising)• loss of consciousness�• severe and persistent headache�• repeated vomiting (two or more occasions)�• post-traumatic amnesia >5 minutes�• retrograde amnesia >30 minutes�• high risk mechanism of injury (road traffic accident, significant fall)�• coagulopathy, whether drug-induced or otherwise.�

Indications for Referral to Hospital

Indications For

CT-SCAN

•eye opening only to pain or not conversing (GCS 12/15 or less)• confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to �improve within •at most one hour of clinical observation or within two hours of injury (whether or •not intoxication from drugs or alcohol is a possible contributory factor)• base of skull or depressed skull fracture and/or suspected penetrating �injuries• a deteriorating level of consciousness or new focal neurological signs�• full consciousness (GCS 15/15) with no fracture but other features, eg�

- severe and persistent headache- two distinct episodes of vomiting

• a history of coagulopathy (eg warfarin use) and loss of consciousness, �amnesia or •any neurological feature.

Indications for CT-Scan

When to discuss with a

Neurosurgeon

•When a CT scan in a general hospital shows a recent intracranial lesion• When a patient fulfils the criteria for CT scanning but �facilities are unavailable• When the patient has clinical features that suggest that �specialist neuroscience assessment, monitoring, or management are appropriate, irrespective of the result of any CT scan.

A patient with a head injury should be discussed with a neurosurgeon:

Head Injury

Closed head injury

Penetrating head injury

Mild Moderate-severe

Cerebral concussion

What is cerebral concussion?“physiologic injury to the

brain without any evidence of structural alteration”

“Many of these patients require only minimal observation after they are assessed carefully, and

many do not require radiographic evaluation.”

Management

• Keep NBM• IV Drip all NS• GCS chart• Vital sign monitoring• Analgesia• Manage other injuries

CPP = MAP – ICP

CPP = cerebral perfusion pressure>70mmHg in adult> 60mmHg in children

CPP = MAP – ICP

MAP= Mean Arterial Pressure= DP + 1/3 (SP - DP)

CPP = MAP – ICP

ICP= Intracranial pressure

Range 5mmHg (infant) to 15mmHg (adult)

CERE

BRAL

BLO

OD

FLO

W

SYSTOLIC BLOOD PRESSURE

50 150

Autoregulation is lost in trauma, resulting in a linear relationship of BP to cerebral blood flow

• Cranium is a closed space• Changes in one of the intracranial components

will result in compensatory alteration in the others

Monroe Kellie Doctrine Principle

Brain 80% Brain 70%

CSF 10%

Blood 10%

CSF 5%

Bloo 5%

Expanding haematoma

CerebralResuscitation

Aim - Prevention of secondary brain insults • Avoid hypotension & maintain CPP• Avoid hypoxia • Decrease ICP • Decrease brain metabolism

Circulatory Support: Maintain Cerebral Perfusion Pressure (50-70mmHg)

0

1

2

3

4

5

6

Outcome

Good

Moderate

Severe

Vegetative

Dead

Number of Hypotensive Episodes

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

Use ofhyperventilation

Use of hyperventilation

• Hyperventilation ↓ PCO2• ↓ PCO2 will cause cerebral vasoconstriction and

reduce cerebral blood flow → ↓ ICP • Harmful effect of reduce blood flow and causing

hypoxia to the brain tissue • Current guideline

– Prophylaxis hyperventilation not recommended – Only used in the management of very acute

elevation of ICP– Moderate (PCO2 30-35mmHg) and transient (<30min)

ReducingIntracranial Pressure

Decrease ICP

• Promote venous return• Decrease metabolism of brain• Decrease brain volume

– Decrease brain blood volume– Decrease CSF volume– Remove space occupying lesion

• Open the skull to give more room

30o

Promote venous return • Keep neck mid-line and elevate head of be to 30⁰ • Early clearance of cervical collar

Dicarlo in ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/\protect/icp-tx-3.htm

Decrease metabolism of brain

• Sedation– Propofol + morphine – Barbiturates – not recommended unless refractory raised

ICP despite maximal medical & surgical intervention • Paralysis

– Stops muscle activity• Anticonvulsants

– Indicated to prevent early PTS (within 7 days)– No benefit for prevention of late PTS– No evidence suggest early PTS a/w poor outcome

• Hypotermia – Reduce metabolic rate – Keep normothermia or mild hypothermia

• T 35-37⁰C

• Treat pain and agitation – consider lignocaine – Consider pre-medication for nursing activities– Allow family contact

Decrease brain volume • Drain CSF – ventricular catheter • Hyperosmolar therapy – reduce oedema

– Mannitol 0.25g-1g/kg body weight (200cc 20% in 20min infusion) effectively reduce ICP

– C/I SBP<90mmHg – Hypertonic saline – possible better than mannitol,

but no strong evidence regarding dose, concentration & administration method

– S/E – rebound phenomenon, central pontine myelinolysis in hypoNa

• Remove blood clot

Indication for Surgery

• EDH – Any GCS, EDH > 30ml– Conservative with serial CT

• <30ml + <15mm thickness + <5mm MLS + GCS>8 + no focal deficit

• SDH– Any GCS, thickness >10mm or MLS >5mm – In patient GCS <9 + thickness <10mm + MLS <5mm,

surgery if GCS droped ≥ 2 or asymmetric/fixed pupil or ICP >20mmHg

Other surgical interventions

• Skull bone elevation – Depressed > thickness of cranium – > 1cm depression – Wound contamination

• Decompressive craniectomy

Other supportive managements

• Infection prophylaxis – Recommended

• Antibiotic for intubation to prevent pneumonia• Early tracheostomy

– Not recommended • Routine change of ventricular catheter/ antibiotic prophylaxis

• DVT prophylaxis – Mechanical prefered – Can use LMWH/ Heparin but with risk of clot expansion

• Prevent bed sore

• Nutrition – Should start immediately if no C/I– Should attain full calories by PTD7

• Glycaemic control – Tight control 4.5-8.5 mmol/L – Hyperglycaemia a/w poor outcome

• Rehabilitation

Conclusion• TBI is a major leading cause of death• Involved high numbers of admission and one

of the highest cost for treatment• Basic knowledge regarding TBI and initial

assessment and treatment is important before referral to neurosurgical team to ensure better outcome of patients

• Keyword – FAST, to prevent secondary brain insult which is a/w poorer outcome

Reference• The Brain Trauma Foundation. Guidelines for the management

of severe traumatic brain injury. http://www.braintrauma.org• The Brain Trauma Foundation. Prehospital Emergency Care• The Brain Trauma Foundation. Early indicators of Prognosis in

Severe Traumatic Brain Injury.• The Brain Trauma Foundation. Surgical Management of TBI

Author Group. • NICE clinical guideline 56. Head injury: triage, assessment,

investigation and early management of head injury in infants, children and adults. http://www.nice.org.uk/CG56

• Clinical Neuroanatomy for Medical Students , Richard S. Snell.