Reviewed and revised 10 March 2014
OVERVIEW
- The management of TBI is focussed on the prevention of secondary injury
PREHOSPITAL CARE
- prevention of secondary injury is the goal
- secure airway by rapid sequence intubation (early intubation of probable benefit but not proven)
- establish normal breathing (normocapnia unless neurological deterioration documented)
- circulation (aggressively avoid hypotension; use crystalloid fluids – avoid albumin solutions)
- protect c-spine
- timely transport to a neurosurgical unit
EMERGENCY DEPARTMENT CARE
- manage with an ATLS protocol
- focussed neurological assessment: GCS, pupils, extent of extremity movements, examine head (e.g. haemotympanum, periorbital or mastoid ecchymosis, CSF rhinorrhoea, otorrhoea)
- haemodynamically stable -> CT
- haemodynamically unstable -> laparotomy, thoracotomy, diagnostic burrholes if there is lateralising neurology (e.g. fixed dilated pupil)
DEFINITIVE TREATMENT
- determined by lesions
- small haematomas usually observed (<10mm)
- haematomas/contusions involving the middle cranial fossa are higher risk (can cause herniation without a rise in ICP)
- penetrating injuries: bullets -> massive destruction, knives -> minimal mass effect but high risk of infection and CSF leak
PHYSIOLOGICAL MONITORING
- standard monitoring required plus invasive pressure monitoring
- ICP monitoring mandatory for severe TBI + abnormal CT as intracranial hypertension develops in 60% (see ICP monitor document)
- EVDs vs Codmans (both have advantages and disadvantages)
SURGICAL INTERVENTIONS
- evacuation of mass lesions
- decompressive craniectomy (controversial, the DECRA study showed harm with early, aggressive decompression)
MEDICAL MANAGEMENT
Resuscitation
- avoid hypoxaemia
— titrated FiO2
— PEEP up to 15cmH2O doesn’t increase ICP significantly - avoid hypotension and hypvolaemia
— use saline and avoid albumin
— use vasopressors
— treat anaemia
Specific therapy
TARGETS
- avoid intracranial hypertension
— sustained ICP > 20mmHg causes ischaemia
- maintain CPP of 60mmHg
— higher produces more ARDS
— lower produces a fall in brain tissue PO2
FIRST TIER
- head up 30 degrees position
- sedation and analgesia
- neuromuscular blockade
— helps control ICP
— increases risk of pneumonia and critical illness polyneuropathy - vent CSF via EVD if raised ICP
- mild hyperventilation to maintain normocarbia
— aim for PaCO2 35mmHg
SECOND TIER
- osmotherapies
— mannitol 0.25-1g/kg Q3hrly
— hypertonic saline (3%) 3 mL/kg over 10 min or 10-20 mL 20% saline
FINAL TIER
- barbiturate coma
— decreases cerebral metabolic rate, but can cause hypotension and has long half life
- therapeutic hypothermia
— lowers ICP but not shown to change outcome (POLAR study is currently in progress) - aggressive hyperventilation
— causes cerebral vasoconstriction
— not used except in rescue situation (e.g. patient coning) - decompressive craniectomy
- lumbar CSF drainage
OTHER
- avoidance of hyperthermia
— increase in neuronal death when > 39 C during first 24 hours
— aggressively cool if T >39 C - seizure prophylaxis
— phenytoin or levitiracetam during first 7 days, but generally on midazolam and propofol
— no evidence of benefit
Supportive care and Monitoring
- DVT prophylaxis
— TEDS + IPC
— can usually use LMWH and UFH within 2-3 days of injury (discuss with neurosurgeon) - nutrition
— early feeding important because of high metabolic requirement - sedation
—  permits manipulation of ventilation, optimisation of cerebral metabolic rate (CMRO2), cerebral blood flow (CBF), and intracranial pressure (ICP)
— also provides anxiolysis, treatment of withdrawal syndromes and seizure control
References and links
Journal articles
- Flower O, Hellings S. Sedation in traumatic brain injury. Emerg Med Int. 2012;2012:637171. doi: 10.1155/2012/637171. Epub 2012 Sep 20. PubMed PMID: 23050154; PubMed Central PMCID: PMC3461283.
- Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med. 2012 Feb 3;20:12. doi: 10.1186/1757-7241-20-12. Review. PubMed PMID: 22304785; PubMed Central PMCID: PMC3298793.
- Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007 Jul;99(1):32-42. Epub 2007 Jun 6. Review. PubMed PMID: 17556349. [Free Full Text]
FOAM and web resources
- BTF — TBI Guidelines
- ICN — Podcast 84: Delaney on Cerebral protection (2013)
- ICN — TBI – ICU Management (1/2) (2013)
- ICN — TBI – ICU Management (2/2) (2013)
http://ceaccp.oxfordjournals.org/content/13/6/189.full