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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Traumatic Brain Injury (TBI) Management

Traumatic Brain Injury (TBI) Management

by Chris Nickson, Last updated May 24, 2016

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)

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

Reader Interactions

Comments

  1. Chris Nickson says

    May 10, 2014 at 6:44 pm

    http://ceaccp.oxfordjournals.org/content/13/6/189.full

    Reply

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