Traumatic Brain Injury (TBI) Management

Reviewed and revised 10 March 2014

OVERVIEW

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

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

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