2. Your Learning Objectives
At the conclusion of this session, you will be able
to:
1. understand the demographics of TBI;
2. discuss the approach to the TBI patient;
3. describe the examination and the evaluation of
the TBI patient;
4. recognize many of the common injuries;
5. be familiar with some of the medical treatment
options;
6. be aware of some of the surgical options; and,
7. appreciate the prognosis in TBI.
3. My Teaching Objectives
Provide a framework for understanding:
1. in an emergency start with ABCs or ABCDEs;
2. remember the GCS as top down and small
number of options to large;
3. think about the rest of your examination
from the top down;
4. think about brain injuries from the outside
in; and,
5. think about TBI treatment in terms of re-
establishing “normal.”
4. “Doctors are men who
prescribe medicines of
which they know little,
to cure diseases of
which they know less, in
human beings of whom
they know nothing.”
– Francois Marie Arouet Voltaire
(1694-1778)
5. 1. Demographics of TBI 2010
> 50 K
Deaths
> 280,000
Hospitalizations
~ 2,500,000 Emergency
Room Visits
? Alternate care or no care
789,925
Men
574,870
Women
At least 3 to 5
million TBIs per
year in the US
6. By cause
All ages Assault
11%
Struck
By/Against
15%
Unknown/
Other
19%
Motor
Vehicle-
Traffic
14%
Falls
41%
9. Schematic behavior ("on autopilot“)
versus attentional behavior (problem-
solving)
Failures of schematic behavior are
“slips” (lapses in concentration, distractions,
or fatigue).
Failures of attentional behavior are
“mistakes” (lack of training or experience).
In health care, most errors are caused by
“slips.”
Checklists reduce the risk of “slips.”
11. Advanced Trauma Life Support (ACS)
www.cdc.gov/TraumaticBrainInjury/
Guidelines for the Management of
Severe Traumatic Brain Injury, 3rd
Edition, 2007
Guidelines for the Surgical
Management of Traumatic Brain
Injury, 2006
Guidelines for Management and
Prognosis of Severe Traumatic Brain
Injury, 2000
Guidelines for the Acute Medical
Management of Severe Traumatic
Brain Injury in Infants, Children, and
Adolescents, 2nd Edition, 2012
12. Ghajar J, Hariri RJ, Narayan RK, Iacono LA, Firlik K, Patterson RH.
Survey of critical care management of comatose, head-
injured patients in the United States.
Critical Care Med. 1995 Mar;23(3):560-7.
Adherence to the TBI guidelines improves
outcomes, but in a survey of ICUs in 45 states:
Only 28% of neurosurgeons routinely measure ICP
83% still use hyperventilation and osmotic diuretics
29% still maintain PaCO2 < 25 mm Hg
44% still use corticosteroids
13. Start with Advanced Trauma Life Support
Primary Survey
ABCDEs
Secondary Survey
GCS from the top down (EVM)
General examination from the top down
Neuro examination from the top down
Tertiary Survey
PMH, FH, SH, Meds, Allergies, ROS
If the patient deteriorates, return to the
primary survey and start over
3. Evaluation of the TBI Patient
14. ATLS primary survey
ABCDE (different than the ABCs of CPR)
Airway (remember the c-spine precautions)
Breathing (exclude pneumothorax,
tamponade, etc)
Circulation (and also control hemorrhage)
Disability/neurological (AVPU [alert, verbal,
painful, unresponsive], pupils and spinal cord
(GCS goes with secondary survey)
Environmental (remove clothes,
correct/prevent hypothermia)
15. ATLS Secondary Survey
Complete history
Top down examination (including GCS)
X-rays and lab
Focused abdominal sonogram for trauma (FAST exam)
Evaluates pericardium, right and left upper abdomen and
pelvic region for blood
CBC, BMP, coags, type and screen, tox, ABG, pregnancy
Non-contrast CTs of C-spine, chest, abdomen, and pelvis
Maintain PaO2 > 60 mm Hg and SBP ≥ 65 mm Hg
16. ATLS Tertiary Survey
Careful and complete examination,
serial assessments, rate of delayed
diagnosis can be 10%
If patient deteriorates, return and
repeat the primary survey
17. History
Events surrounding the
accident
Seatbelt, helmet, position in
motor vehicle, direction of
impact, speed, damage to
windshield or steering wheel
Assess for EtOH or illicit drugs
Drugs may confound the
examination
Was there a seizure at the
time of the accident
18. History
Mechanism
of Injury
Rotational most
likely to cause
shearing
Lateral and AP cause
coup and contra-
coup
and subdurals
Local injury to the
temporal bone
causes epidurals
19. Examination—General
Head
Scalp lacerations
May be associated with significant blood loss
Depressed skull fracture (convexity fractures)
Most skull fractures non-displaced
CSF rhinorrhea or otorrhea, raccoon eyes, Battle’s sign
(basilar skull fractures)
Significant head injuries can occur without external
stigmata
Spine
Step-off
Tenderness
Passive rewarming
Hypothermia may confound the neurological examination
20. Examination—Glasgow Coma Scale
GCS 13-15 is
“mild”
GCS 9-12 is
“moderate”
GCS 3-8 is
“severe” and
equates to coma
Motor
Top Down
4
5
6
21. Examination—Glasgow Coma Scale
Top down (EVM); fewest categories to most.
Motor
Top Down
4
5
6
1 None
2 Decerebrate
3 Decorticate
4 Withdraws
5 Localizes
6 Normal
Motor
1 None
2 Sounds
3 Word Salad
4 Disoriented
5 Normal
Verbal
1 None
2 To Pain
3 To Voice
4 Normal
Eyes
22. Neurological Examination
A complete neurological examination on every
patient (organized from top down)
Mental status
Cranial Nerves (including pupils)
Motor (rate power from 0/5 to 5/5)
Sensory (light touch and pin prick)
Reflexes (0, 1, 2, 3, 4)
Coordination/Gait
24. Fixed and Dialated Pupils
No patient with bilateral
fixed and dilated pupils
for more than 90 minutes
had a favorable
outcome.
Many surgeons will
consider surgery futile if
3 to 6 hours have
elapsed.
26. Indications for CT
Mild TBI (GCS ≥ 13)
New Orleans Criteria
No CT if GCS 15, + LOC, no neuro deficit, age > 3 years
CT if headache, vomiting, seizure, intoxication, short term memory
deficit, age > 60, injury above the clavicle
Canadian CT Head rule
No CT if GCS 13-15, + LOC, no neuro deficit, no seizure, no
anticoagulation, age > 16 years
CT if:
High risk—GCS < 15 after 2 hours, suspected convexity or basilar skull
fracture, vomiting ≥ 2 times, or age ≥ 65; or,
Medium risk—retrograde amnesia > 30 minutes, severe mechanism
(pedestrian vs. car, ejected from car, or fall from > 1 m or five stairs)
27. Indications for CT
Moderate TBI (GCS 9-12) or Severe TBI (GCS ≤ 8)
All get a head CT
CT is positive in 93% of patients with a severe TBI
A negative CT does not guarantee a “favorable” prognosis
Obliteration of basal cisterns associated with “unfavorable”
outcomes in 97% of cases
45. Marshall Classification of CT findings
Diffuse injury I—No visible pathology on CT
Diffuse injury II—Cisterns present, midline shift <
5 mm, no high-density lesion > 2.5 cm
Diffuse injury III—Cisterns compressed or absent,
no high-density lesion > 2.5 cm
Diffuse injury IV—Midline shift > 5 mm, no high-
density lesion > 2.5 cm
Evacuated mass—Any lesion surgically evacuated
Non-evacuated mass—High-density lesion > 2.5
cm but not surgically evacuated
48. 5. Medical Treatment Options
Primary Injury
Occurs at the moment of trauma
Contusion, damage to blood vessels, axonal shearing, blood brain barrier
changes, fractures, and meningeal injury
Secondary Injury
Begins in the hospital (causes significant disability, preventable)
Ischemia and cerebral hypoxia (due to hypotension and impaired autoregulation)
Cerebral edema (raised intracranial pressure, brain herniation)
Metabolic changes such as hypercapnia and acidosis
Infection (meningitis, brain abscess)
Release of neurotransmitters (excitotoxicity)
Viscous Cycles (edema causes more ischemia which causes more edema)
Systemic complications (pneumonia, DVT)
49. TBI Guidelines 3rd Edition, 2007
Three classes of evidence
Class I: Relevant screening test; credible reference standard;
reference standard independent of screening test; reliability of test
assessed; few indeterminate results; large number of patients.
Class II: Relevant screening test; reasonable although not best
standard; standard independent of screening test; moderate number
of patients.
Class III: Has fatal flaws; inappropriate reference standard; screening
tests improperly administered; small number of patients.
Three levels of recommendation (based on class of evidence,
highest level with at least one recommendation given)
15 categories, only 14 stated “level of evidence”
Level I: 1/14 (steroid use)
Level II: 10/14 (BP, Mannatol, Abx, ICP monitoring, ICP threshold,
CPP, anesthetics, nutrition, Sz meds, hyperventilation)
Level III: 3/14 (hypothermia, DVT, brain O2 monitoring)
50. I. Blood Pressure and Oxygenation
B. Level II—Hypotension (SBP < 90 mmHg) should be avoided.
C. Level III--Hypoxia (PaO2 < 60 mmHg or O2 saturation < 90%)
should be avoided
Single most important intervention is maintaining SBP and CBF
CBF should be between 50 and 70
Under 50, risk of ischemia
Over 70, risk of ARDS
TBI Guidelines (I)
51. TBI Guidelines (II)
II. Hyperosmolar Therapy
B. Level II--Mannitol is effective to treat ICP. Doses of 0.25 to 1
g/kg.
C. Level III--Restrict mannitol use prior to ICP monitoring to
patients with signs of herniation or progressive neurological
deterioration.
Albumen, SAFE trial of 7000 patients, ↑ ICP, No Benefit
Hypertonic Saline
↓ cerebral edema, ↑ flow through small vessels, ↑ MAP
Avoids the diuresis, ↓ BP seen, and renal issues with Mannitol
Mannitol
Rapid decrease ICP in emergencies
Renal damage if Osm over 320
53. TBI Guidelines (III)
III. Prophylactic Hypothermia
C. Level—Better outcomes with temperatures of 32–33°C for > 48
hours. Difficult to do.
First studies by Temple Fay (1895-1963,
Temple U)
↓ metabolic rate, ↓ apoptosis
↓ neuroexcitatory damage, ↓ inflammatory
damage, ↓ free radicals
↓ Cerebral Blood Flow, ↓ ICP
But
↓ Platelet Function
Rewarming Problems (↑ K+, ↓ glucose)
54. TBI Guidelines (III)
Prophylactic Hypothermia
Tylenol, fans, ice bags, etc—not
adequate
Intravenous heat exchangers may be
effective
Shivering can be controlled with
warming of the hands
Induced Normothermia
Preventing fever spikes may be as
advantageous as hypothermia
Pending studies
Eurotherm 3235 (600 patients) - UK
POLAR-RCT (500 patients) – Australia
and NZ
55. TBI Guidelines (IV and V)
IV. Infection Prophylaxis
B. Level II--Periprocedural antibiotics for intubation should be administered. Early tracheostomy should be
performed to reduce ventilator days.
C. Level III--Routine ventricular catheter exchange or prophylactic antibiotic use is not recommended.
V. Deep Vein Thrombosis Prophylaxis
C. Level III--Compression stockings are recommended. Low molecular weight heparin (LMWH) or low dose
unfractionated heparin should be used, however, there is an increased risk of hemorrhage. There is no clear
preferred agent.
There are NO guidelines for Lovenox or similar in patients with TBI.
Giving Lovenox BEFORE a craniotomy is NOT safe.
In patients with a “bleed,” starting Lovenox 24 to 48 hours AFTER the CT has stabilized and there is no more
bleeding is probably safe.
In post-op craniotomy patients, starting Lovenox 24 or 48 hours after surgery, or when the drains stop producing
fresh blood, is probably safe.
56. TBI Guidelines (VI through VIII)
VI. Indications for Intracranial Pressure Monitoring
B. Level II--Monitor Intracranial pressure (ICP) in all salvageable patients with a
severe TBI (GCS 3–8) and an abnormal CT scan.
C. Level III--ICP monitoring is indicated in patients with severe TBI with a normal
CT scan if two or more of the following: age over 40 years, unilateral or bilateral
motor posturing, or SBP < 90 mm Hg.
VII. Intracranial Pressure Monitoring Technology
A ventricular catheter and an external strain gauge is the most accurate, low-cost,
and reliable method. It can be recalibrated. Strain gauge devices provide similar
benefits, but cost more and cannot be recalibrated.
VIII. Intracranial Pressure Thresholds
B. Level II—Treat ICPs above 20 mm Hg.
C. Level III—Use a combination of ICP values, clinical findings, and CT findings to
guide treatment (common sense).
57. TBI Guidelines (VI through VIII)
(Monro-Kellie doctrine)
Alexander Monro (1733-
1817), Scottish a famous-
anatomist, surgeon, and
lecturer
George Kellie (1720-
1779), Scottish anatomist
and surgeon who studied
under Monro
58. TBI Guidelines (VI through VIII)
Brain
Arterial Blood
Venous Blood
CSF
ECF
140 to 270 cc
of CSF (25 in
the ventricles)
1050 to 1150
cc of brain
200 cc of ECF
100 cc of
venous blood
50 cc of
arterial blood
Mannitol
Ventricular
DrainageHyper-
ventilation
63. TBI Guidelines (IX and X)
Cerebral Perfusion Pressure is MAP minus ICP.
If MAP is 90 and ICP is 20, CPP is 70.
CPP should be 50 to 70 mmHg.
CPP over 70—ARDS more likely.
CPP less than 50—No brain perfusion!
65. TBI Guidelines (VI through VIII)
ICP Monitoring Technology
A ventricular catheter and external strain gauge are the
most accurate, reliable, and method of monitoring.
Ventriculostomies allow CSF Drainage.
66. Convenient, fast,
accurate.
Cannot be
recalibrated after
insertion, and are
expensive ($6,000
to $10,000).
TBI Guidelines (VI through VIII)
ICP Monitoring Technology
72. TBI Guidelines (IX and X)
IX. Cerebral Perfusion Thresholds
B. Level II—Ovrly aggressive attempts to keep CPP > 70 mm Hg with fluids and
pressors should be avoided because of the risk of adult respiratory distress
syndrome (ARDS).
C. Level III--CPP of < 50 mm Hg should be avoided. The CPP value to target lies
within the range of 50–70 mm Hg.
X. Brain Oxygen Monitoring and Thresholds
C. Level III—Maintain jugular venous saturation > 50% or brain tissue oxygen tension
>15 mm Hg.
The technology exists but is limited.
73. TBI Guidelines (XI to XV)
XI. Anesthetics, Analgesics, and Sedatives
B. Level II--Prophylactic barbiturates not recommended. Barbiturates for ICP refractory
to all other treatment helpful but cause significant morbidity.
XII. Nutrition
B. Level II--Full caloric replacement by day 7.
XIII. Anti-seizure Prophylaxis
B. Level II—Prophylactic, long-term anti-epileptics not recommended. Anticonvulsants
decrease early seizures but early seizures not associated with worse outcomes.
XIV. Hyperventilation
B. Level II--Prophylactic hyperventilation (PaCO2 < 25 mm Hg) is dangerous.
C. Level III--Temporizing measure only. Most harmful early when CBF most reduced.
XV. Steroids
A. Level I—Steroids are not recommended—cause increased mortality.
This is the only level II recommendation.
74. TBI Guidelines Summary
Intubate if:
Poor airway protection
or GCS ≤ 8
Extubate early
PaO2 > 60 mmHG or O2
Sat > 90%
PaCO2 = 35 to 40 mm
HG
Keep SBP > 90 and CPP
50-70
A single episode of
hypotension doubles
mortality
Avoid hypotonic
solutions (LR or ½ NSS)
Avoid hyperglycemia
75. Mannitol
Signs of herniation or
progressive
deterioration not due
to extracranial causes
Dose 0.25 to 1 g/Kg
Avoid before ICP
monitoring
Avoid if hypotensive
Hypothermia QUESTIONABLE.
Steroids NOT helpful.
Anticonvulsants NOT for
prophylaxis.
Antibiotics NOT for prophylaxis.
Hyperventilation NOT advised.
Full caloric replacement early.
DVT prophylaxis (SCDs, +/-
anticoagulation).
Avoid high dose Propofol.
Barbiturates only in
desperation.
TBI Guidelines Summary
76. TBI Guidelines Summary
Monitor ICP in all “severe” head injury
patients (GCS ≤ 8) with an abnormal CT.
Monitor ICP in all “severe” head injury and a
normal CT if two or more of the following:
Age ≥ 40 years;
Systolic blood pressure ≤ 90 mm Hg; and,
Unilateral or bilateral posturing.
77. Not in the TBI Guidelines
Decompressive Craniectomy
Has waxed and waned in popularity over the last 30 years
Indications now not entirely clear.
May be helpful for hemispheric or MCA strokes.
For TBI, probably to be done in desperation only.
A very large craniectomy is required.
May occasionally cause worse problems (strangulation of the
brain under the new defect).
May convert deaths into vegetative survivors.
78. Not in the TBI Guidelines
Transfusion thresholds
Historical: 30% or 10 g/dL
Reassessed 1980s—infection risk and cost
AABB Guidelines (2012)
Hgb <6 g/dL – Transfusion recommended
Hgb 6 to 7 g/dL – Transfusion generally indicated
Hgb 7 to 8 g/dL – Transfusion should be considered in postoperative
surgical patients
Hgb 8 to 10 g/dL – Transfusion generally not indicated, but should be
considered for: symptomatic anemia; ongoing bleeding; acute
coronary syndrome (cardiac surgery literature supports 30%)
Transfusion thresholds for TBI undefined
Some including Carlson, 2006, suggest that the same guidelines apply
Many neurosurgeons believe that because of the brain’s higher O2
consumption, a hematocrit near 30% reduces risk and improves
outcome.
79. 6. Surgical Management of TBI 2006
Addresses Four Classes of
Lesion
Epidural Hematomas
Subdural Hematomas
Contusions (Parenchymal
Lesions)
Posterior Fossa Mass Lesions
80. Surgical Management of Epidurals
Indications for Surgery
An epidural over 30 cm3 should be removed regardless of the GCS score.
An epidural less than 30 cm3 and with less than a 15-mm thickness and
with less than a 5-mm midline shift and with a GCS score greater than 8
without focal deficit can be managed nonoperatively but need serial
scans and close follow-up.
Timing
Patients with an acute epidural in coma with anisocoria need surgery
immediately.
Methods
Craniotomy.
Exceptions
Venous epidurals.
81. How do you determine volume on CT
Kothari, et al, 1996.
Find largest diameter (call it A)
Find diameter at 90 degrees to A (call it B)
Count the CT slices where the clot is seen and multiply
by slice thickness to find the depth (call that C)
Lesion volume =
𝑨 ∗𝑩 ∗𝑪
2
In a 30 cc lesion, the average value of A, B, and C is
about 4 cm or 1½ inches
88. Surgical Management of Subdurals
Indications for Surgery
An acute subdural 10 mm thick or a midline shift over 5 mm should be
removed regardless of the GCS.
• All patients with an acute SDH in coma (GCS score less than 9) should
undergo intracranial pressure (ICP) monitoring.
• A comatose patient with a SDH < 10-mm thick and a shift < 5 mm needs
surgery if the GCS decreased between injury and admission or if pupillary
changes or if the ICP exceeds 20 mmHg.
Timing
Patients with an acute subdural in coma with anisocoria need surgery
immediately.
Methods
Craniotomy
95. Surgical Management of Contusions
Indications
Patients with parenchymal lesions and
neurological deterioration, medically
refractory ↑ ICP, or mass effect on CT
needs surgery.
Patients with GCS of 6 to 8, with
frontal or temporal contusions greater
than 20 cm3 in volume with shift > 5
mm or loss of basal cisterns, and
patients with lesions over 50 cm3
need surgery.
Patients with mass lesions who do not
show evidence of neurological
compromise, have low ICP, and no
signs of mass effect on CT may be
observed with serial CTs.
96. Surgical Management of Contusions
Timing and Methods
Bifrontal decompressive
craniectomy, within 48 hours
of injury, should be
considered for diffuse
cerebral edema.
Decompressive procedures
(subtemporal decompression,
temporal lobectomy, and
hemispheric decompressive
craniectomy) are options for
patients with ↑ ICP.
97. Surgical Management of Posterior Fossa
Lesions
Indications
Patients with mass effect on CT or with neurological dysfunction or
deterioration need surgery. Mass effect is distortion of the fourth
ventricle, compression of the basal cisterns, or hydrocephalus.
Patients with lesions but no mass effect on CT or neurological deficit
may be observed and imaged serially.
Timing
Patients can deteriorate rapidly. Surgery should be done immediately.
Methods
Suboccipital craniectomy is used to evacuate posterior fossa lesions.
103. 7. Prognosis (2000)
Relatively few features have
been found to contain most of
the prognostic information.
Patient Age
Severity of Injury
Difficult to quantify
Intracranial pressure
Not always measured
Computed tomography (CT)
104. Prognosis (2000)
Glasgow Coma Score (severity of
injury)
Works well for very low and very high
initial GCS scores.
Age
Younger patients do better and those
over 60 worse
Pupillary reactivity (severity of injury
and ICP)
Hypotension
Strongly predicts a poor outcome
The only factor that can be changed
CT abnormalities predict a poor
outcome (severity of injury and ICP)
105. Glasgow Outcome Score (GOS)
1 GR Good recovery—resumption of normal life despite minor
deficits.
2 MD Moderate disability (disabled but independant)—travel
by public transportation, can work in sheltered setting
(exceeds mere ability to perform “ADLs”).
3 SD Severe disability (conscious but disabled)—dependent
for daily support (may be institutionalized, but this is not a
criteria).
4 PVS Persistent vegetative state—unresponsive and
speechless; after 2-3 weeks may open eyes and have
sleep/wake cycles.
5 D Death—most deaths from primary head injury occur
within 48 hours.
106. 1—Death (D)
2—Vegitative
State (VS)
3—Lower
Severe
Disability (SD-)
4—Upper
Severe
Disability (SD+)
5—Lower
Moderate
Disability (MD-)
6—Upper
Moderate
Disability (MD+)
7—Lower Good
Recovery (GR-)
8—Upper Good
Recovery (GR+)
Glasgow Outcome Score-Extended (GOS-E)
Reversed the numbers
Added “lower” and “upper” to the three intermediate categories
107. 75% “mild”
Thinking
memory and reasoning
Sensation
vision, smell, and taste
Language
communication, understanding
Emotion
anxiety, depression, personality,
inappropriate behavior
25% “Moderate” or “Severe”
Seizures
Parkinson’s Disease
Dementia
Paralysis
PVS
Spectrum of Effects of TBI
(numerous independent variables)
108. More Pearls
Mortality from epidural hematoma
about 10%.
Mortality from subdural hematoma 40
to 60%.
Hypoxia increases mortality.
Hypotension doubles mortality.
Recovery may continue for a year or
more.
109.
110. Organize
With a TBI start with ABCDEs.
Remember the GCS as top down and small
number of options to large.
Think about the rest of your examination
from the top down.
Think about brain injuries from the outside
in.
Think about TBI treatment in terms of
keeping all the numbers normal.
