Integrated First Line and Hospital-based Management of Traumatic Brain Injury including ATLS protocols, with advanced EM and Surgical interventions.

1. MANAGEMENT OF TRAUMATIC BRAIN INJURY
Areeba Mustafa

2. Management of Traumatic Brain Injury depends upon classisification and evaluation of
TBI. According to the CDC, the severity of traumatic brain injury (TBI) is typically
defined by the initial Glasgow Coma Scale (GCS) or Pediatric Glasgow Coma Scale
Score.
●Mild (GCS score 13 to 15)
●Moderate (GCS score 9 to 12)
●Severe (GCS score <9)
Classification & Evaluation

4. Mild traumatic brain injury is also called a concussion.
Someone with an mTBI may or may not have lost consciousness, but for a
very short time.
Such patients kept at regular observations for emergence of neurological
or functional impairment by neurologists or general physicians for a
considerable period of time and hospital admissions are not required.
MANAGEMENT OF MILD TBI
(GCS 13 TO 15)

5. Prevention of secondary brain injury is the primary concern of therapeutic
interventions and management following TBI, which can be best managed
by a multidisciplinary team of neurosurgeons, neurophysicians and
emergency physicians.
Secondary brain injury refers to the aggravation of TBI over subsequent
minutes to hours as a consequence of various factors, such as hypoxemia,
hypotension, hypo- or hyper-carbia, hypo- or hyper-glycemia, hypo- or
hyper-thermia, and seizures.
MANAGEMENT OF MODERATE AND
SEVERE TRAUMATIC BRAIN INJURY

6. PRE HOSPITAL MANAGEMENT
• Care of a TBI patient should begin at the site of the injury, with an aim to secure the
patients' airway and maintain adequate ventilation and circulation.
• Patients with moderate or severe TBI should be transferred to a tertiary care
center with neurosurgical facilities as soon as possible.
• The primary management goals are the prevention of hypoxia and hypotension,
because even a single episode of hypotension has been found to be associated
with a doubling of mortality and an elevated risk of morbidity

7. IN-HOSPITAL MANAGEMENT PROTOCOLS

8. Glasgow coma scale (GCS) has been the most widely used method
of recording the level of consciousness in patients at presentation
and at subsequent assessments.
1. Neurological Assessment

9. 2. Airway Control and Ventilation
• Basic airway care performed well in a prehospital setting may be significantly
better than prehospital intubation
• Patients with TBI have up to a 5% to 6% incidence of an unstable cervical spine
injury.
• All attempts at intubation should include in-line neck stabilization to reduce
the chance of worsening a cervical spine injury.
• Pre-existing hypoxia, intracranial hypertension, full stomach, and coexisting
injuries, such as cervical spine trauma and maxillofacial injuries, may be
present that predisposes a patient to difficult airway management. Thus,
careful preparation and preoxygenation is mandatory.

10. Use Anesthetic drugs that allow for rapid control of the airway while avoiding an
increase in Intracranial Pressure (ICP) and providing hemodynamic stability.
1. Propofol (risk of hypotension, but commonly used)
2. Thiopental (risk of hypotension)
3. Etomidate (provide better hemodynamic stability, mild risk of adrenal
suppression )
4. Ketamine (preferred in trauma patients, limited effect on ICP)

11. • For rapid sequence intubation, succinylcholine or rocuronium may be used.
• Adequate sedation and muscle relaxation to reduce the cerebral metabolic oxygen
requirement (CMRO2), optimize ventilation, and prevent coughing or straining.
• Maintain PCO2 within a normal range of 34–38 mmHg. Hypoventilation should be
avoided.
• Hyperventilation results in an increased risk of vasoconstriction so it should also be
avoided.
• Fraction of inspired oxygen (FiO2) should be adjusted to achieve a PaO2 of ~90 mmHg.
High PaO2 should be avoided.
• PEEP of 5–10 cmH2O may be administered to prevent atelactasis.

12. 3. Blood Pressure and Cerebral Perfusion Pressure (CPP)
• Maintain SBP at ≥ 100 mmHg for patients 50 to 69 years old
• Maintain SBP ≥ 110 mmHg or above for patients 15 to 49 or over
70 years old.
• The recommended target CPP value is between 60 and 70 mmHg.
• These values can be acheived by using different vasopressors like
Epinephrine, Dopamine and Phenylephrine

13. 4. Fluid Management
• Patients should have adequate venous access (eg, two large-bore peripheral intravenous
catheters) in place.
• To estimate the extent of hypovolemia
1. Analyses of the arterial pulse pressure variation
2. blood pressure response following a fluid challenge
3. Passive leg raise.
• Isotonic Saline or Ringer's lactate are used.

14. 5. Sedatives and Analgesics
• Sedative like Barbiturates can reduce metabolic stress on acutely injured brain
tissue.
• Maintain an adequate mean arterial pressure throughout the duration of
sedation.
• An adequate level of sedation is paramount because it minimizes the length of
hospital stay, ventilator days, incidence of delirium.

15. 6. ICP Monitoring and Management
• Updated BTF guidelines recommend treatment of ICP > 22 mmHg to reduce mortality.
• Method of ICP monitoring: external ventricular drain (EVD) technique, in which a catheter is placed
into one of the ventricles through a burr hole (gold standard of ICP monitoring)
• . In addition to measuring ICP, this technique can also be used to drain cerebrospinal fluid and
administer medicine intrathecally, such as for antibiotic administration in cases of ventriculitis.

17. 7. Osmotherapy
• By Mannitol (0.25-1 gram/kg) or Hypertonic Saline for the
treatment of raised ICP.

18. 8. Temperature Management
• Mild hyperthermia is associated with poorer outcomes and longer ICU
stays, as it is may lead to increased edema and inflammation
• Antipyretics and cooling blankets can be used in patients with severe
TBI.

19. 10. Surgical Management: Decompressive Craniectomy
• It involves removal of a large section of the skull.
• Craniectomy reduces ICP by giving extra space to the
swollen brain if ICP is remaining persistently elevated
and is unresponsive to osmotherapy, drainage of CSF
and other medical measures.
• It may quickly prevent brainstem herniation.

20. 11. Nutrition
• Early Nutritional Support preferrably enteral
• Basic Caloric Replacement by at least 5th day
• Transgastric jejunal feeding to avoid risk of VAP
• Prokinetic drugs like Metoclopramide to improve feeding
tolerance commonly encountered in severe TBI.

21. 12. Antibiotic Therapy
• Monitor for signs of infection especially with invasive
ICP monitoring and mechanical ventilation
• Conservative antibiotic therapy can be instituted

22. OUTCOMES OF
TRAUMATIC
BRAIN INJURY

23. Amnesia and Confusion
Loss of Consciousness
Dazed appearance and
slurred speech
Motor deficits and
Delayed responses
Immediate or
Early
Outcomes

24. Fatigue and Headaches
Nausea and Vomiting
Neck Stiffness
Loss of balance and
hearing impairment
Immediate or
Early
Outcomes

25. Delayed or Long-Term Outcomes
• Anxiety
• Blurred vision
• Car sickness or motion sickness
• Change in sense of taste or smell
• Depression
• Difficulty in concentration
• Difficulty finding things and reading

26. • Easy to distract
• Feeling of overwhelm
• Sensitivity to light and noise
• Sleep disturbances
• Short term memory problems
• Difficulty with executive function
• Mood/personality changes
• Occassional heartbeat irregularities