Traumatic Brain Injury (TBI) Management

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)