Guidelines in hospital care

1. TBI GUIDELINES-
IN-HOSPITAL CARE
Dr Sumit Sinha
Additional Professor
Deptt of Neurosurgery, JPNA Trauma
Center and AIIMS, New Delhi, India

2. TBI GUIDELINES- IN-HOSPITAL CARE
• Trauma care systems in India- nascent stage of
development.
• Complete lack of an organized trauma care- gross
disparity between trauma services
• No mechanisms for accreditation of trauma centers
and professionals.
• Need of creating a rationale for developing
guidelines and protocol.

3. TBI- Current status- Problems
• In the absence of guidelines- prehospital and
hospital-based critical care varies enormously.
• Available personnel and their skills often do
not match the needs of the patients.
• The concept of a dedicated trauma team is
not accepted at all levels.

4. TBI- Current status- PROBLEMS
TBI In-hospital Care- PESSIMISTIC SITUATION !!
• No Guidelines YET
• Financial Constraints
• Lack of Public Awareness
• Lack of trained Manpower
• Lack of Dedicated trauma centers
• ABSENT Referral system
• Lack of nationwide regulatory policies

6. TBI GUIDELINES- IN-HOSPITAL CARE
Level Facilities
I 24 hr neurosurgery and neurocritical care, CT
scan, ICP monitoring, All specialities
Severe TBI
II Neurosurgery on call < 1 hr, Basic ICU, CT,
Most trauma specialties
Mild, moderate, severe TBI requiring
Neurosurgery
III CT, General surgery, orthopedics Mild TBI requiring CT means for
consulting neurosurgery
IV Able to handle most ABC’s Mild TBI not requiring CT
V Basic ABC’s, may not be intubation GCS 15 not requiring CT, No ABC
issues, no other significant trauma
Hospital Categories

7. TBI GUIDELINES- IN-HOSPITAL CARE
Distribution of hospitals
• Every state- at least one Level I Center
• Level 2- in large metropolitan areas
• Every district hospital- at least level 3 facilites
System to categorize and verify facilities
System to ensure that hospital provides the care
expected

8. TBI GUIDELINES- IN-HOSPITAL CARE
AIRWAY MANAGEMENT

9. TBI GUIDELINES- IN-HOSPITAL CARE
AIRWAY MANAGEMENT

10. TBI GUIDELINES- IN-HOSPITAL CARE

11. TBI GUIDELINES- IN-HOSPITAL CARE

12. TBI GUIDELINES- IN-HOSPITAL CARE

13. TBI GUIDELINES- IN-HOSPITAL CARE

14. TBI GUIDELINES- IN-HOSPITAL CARE
CLINICAL MONITORING
All personnel involved in monitoring a head
injury patient must be trained to assess the
Glasgow Coma Scale and pupils.

15. TBI GUIDELINES- IN-HOSPITAL CARE
Response to deterioration
• Report immediately
• Rapid decision to be made on the need for
– Repeat investigation
– Referral
– Transfer to ICU / OR

16. TBI GUIDELINES- IN-HOSPITAL CARE
• Deteriorating GCS
• Focal or abnormal neurological signs
• Early post-traumatic seizure
• Skull fracture
• High-risk mechanism of injury
• Patients whose GCS has not returned to 15 after imaging, regardless of the
imaging results.
• Pt has indications for CT but this cannot be done (CT not available or pt not
cooperative)
• persistent vomiting, severe
headaches, amnesia
• Drug or alcohol intoxication, other
injuries, shock, suspected non-
accidental injury, meningism,
cerebrospinal fluid leak where a scalp
laceration overlies a fracture, or the
person’s age.
• No responsible caregiver under
whose care the person could be
discharged.
• ‘Mild’ head injuries with symptoms
such as headache, photophobia,
nausea and vomiting, or amnesia
requiring management.
Criteria for admitting patients to hospital following TBI

17. TBI GUIDELINES- IN-HOSPITAL CARE
Criteria for performing a CT Scan

18. TBI GUIDELINES- IN-HOSPITAL CARE

19. TBI GUIDELINES- IN-HOSPITAL CARE

20. TBI GUIDELINES- IN-HOSPITAL CARE

21. TBI GUIDELINES- IN-HOSPITAL CARE
Nutrition
Deep venous thrombosis prophylaxis
Glucose Management
Analgesics & Sedatives
Infection prophylaxis
Antiepileptic drugs
DISCHARGE AND FU

22. TBI- Current status
GUIDELINES ???
• Formulation- Probably not a problem at all
• Enforcement- YES !!!
Together we can
And
Together we MUST !!