Indication for intubation GCS ≤ 8 Loss of protective laryngealUnable to maintain airway reflexes Unstable facial bone # Bleeding into mouth SeizuresVentilatory insufficiency Spontaneous hyperventilation Irregular respiration
Indications for Referral to Hospital•GCS<15 at initial assessment for two hours and refer if GCS scoreremains<15 after this time)•ƒ post-traumatic seizure (generalised or focal)•ƒ focal neurological signs•ƒ signs of a skull fracture (including cerebrospinal fluid from nose orears,haemotympanum, boggy haematoma, post auricular or periorbitalbruising)•ƒ loss of consciousness•ƒ severe and persistent headache•ƒ repeated vomiting (two or more occasions)•ƒ post-traumatic amnesia >5 minutes•ƒ retrograde amnesia >30 minutes•ƒ high risk mechanism of injury (road traffic accident, significant fall)•ƒ coagulopathy, whether drug-induced or otherwise.
Indications for CT-Scan•eye opening only to pain or not conversing (GCS 12/15 or less)•ƒ confusion or drowsiness (GCS 13/15 or 14/15) followed by failure toimprove within•at most one hour of clinical observation or within two hours of injury(whether or•not intoxication from drugs or alcohol is a possible contributory factor)•ƒ base of skull or depressed skull fracture and/or suspected penetratinginjuries•ƒ a deteriorating level of consciousness or new focal neurological signs•ƒ full consciousness (GCS 15/15) with no fracture but other features, eg - severe and persistent headache - two distinct episodes of vomiting•ƒ a history of coagulopathy (eg warfarin use) and loss of consciousness,amnesia or•any neurological feature.
A patient with a head injury should be discussed with a neurosurgeon:•When a CT scan in a general hospital shows a recentintracranial lesion•ƒ When a patient fulfils the criteria for CT scanning butfacilities are unavailable•ƒ When the patient has clinical features that suggestthat specialist neuroscience assessment, monitoring, ormanagement are appropriate, irrespective of the result ofany CT scan.
Head Injury Closed Penetrating head injury head injury Mild Moderate- severe Cerebralconcussion
What is cerebral concussion? “physiologic injury to the brain without any evidence of structural alteration”
“Many of these patients require only minimalobservation after they are assessed carefully, and many do not require radiographic evaluation.”
Management• Keep NBM• IV Drip all NS• GCS chart• Vital sign monitoring• Analgesia• Manage other injuries
CPP = MAP – ICPCPP = cerebral perfusion pressure >70mmHg in adult > 60mmHg in children
CEREBRAL BLOOD FLOW 50 150 SYSTOLIC BLOOD PRESSUREAutoregulation is lost in trauma, resulting in a linearrelationship of BP to cerebral blood flow
Monroe Kellie Doctrine Principle• Cranium is a closed space• Changes in one of the intracranial components will result in compensatory alteration in the others Brain 80% Brain 70% Expanding haematoma CSF Blood CSF Bloo 10% 10% 5% 5%
Use of hyperventilation• Hyperventilation ↓ PCO2• ↓ PCO2 will cause cerebral vasoconstriction and reduce cerebral blood flow → ↓ ICP• Harmful effect of reduce blood flow and causing hypoxia to the brain tissue• Current guideline – Prophylaxis hyperventilation not recommended – Only used in the management of very acute elevation of ICP – Moderate (PCO2 30-35mmHg) and transient (<30min)
Decrease ICP• Promote venous return• Decrease metabolism of brain• Decrease brain volume – Decrease brain blood volume – Decrease CSF volume – Remove space occupying lesion• Open the skull to give more room
Promote venous return• Keep neck mid-line and elevate head of be to 30⁰• Early clearance of cervical collar Dicarlo in ALL-NET Pediatric Critical Care Textbook www.med.ub.es/All-Net/english/neuropage/protect/icp-tx-3.htm
Decrease metabolism of brain• Sedation – Propofol + morphine – Barbiturates – not recommended unless refractory raised ICP despite maximal medical & surgical intervention• Paralysis – Stops muscle activity• Anticonvulsants – Indicated to prevent early PTS (within 7 days) – No benefit for prevention of late PTS – No evidence suggest early PTS a/w poor outcome
• Hypotermia – Reduce metabolic rate – Keep normothermia or mild hypothermia • T 35-37⁰C• Treat pain and agitation – consider lignocaine – Consider pre-medication for nursing activities – Allow family contact
Decrease brain volume• Drain CSF – ventricular catheter• Hyperosmolar therapy – reduce oedema – Mannitol 0.25g-1g/kg body weight (200cc 20% in 20min infusion) effectively reduce ICP – C/I SBP<90mmHg – Hypertonic saline – possible better than mannitol, but no strong evidence regarding dose, concentration & administration method – S/E – rebound phenomenon, central pontine myelinolysis in hypoNa• Remove blood clot
Indication for Surgery• EDH – Any GCS, EDH > 30ml – Conservative with serial CT • <30ml + <15mm thickness + <5mm MLS + GCS>8 + no focal deficit• SDH – Any GCS, thickness >10mm or MLS >5mm – In patient GCS <9 + thickness <10mm + MLS <5mm, surgery if GCS droped ≥ 2 or asymmetric/fixed pupil or ICP >20mmHg
Other surgical interventions• Skull bone elevation – Depressed > thickness of cranium – > 1cm depression – Wound contamination• Decompressive craniectomy
Other supportive managements• Infection prophylaxis – Recommended • Antibiotic for intubation to prevent pneumonia • Early tracheostomy – Not recommended • Routine change of ventricular catheter/ antibiotic prophylaxis• DVT prophylaxis – Mechanical prefered – Can use LMWH/ Heparin but with risk of clot expansion• Prevent bed sore
• Nutrition – Should start immediately if no C/I – Should attain full calories by PTD7• Glycaemic control – Tight control 4.5-8.5 mmol/L – Hyperglycaemia a/w poor outcome• Rehabilitation
Conclusion• TBI is a major leading cause of death• Involved high numbers of admission and one of the highest cost for treatment• Basic knowledge regarding TBI and initial assessment and treatment is important before referral to neurosurgical team to ensure better outcome of patients• Keyword – FAST, to prevent secondary brain insult which is a/w poorer outcome
Reference• The Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. http://www.braintrauma.org• The Brain Trauma Foundation. Prehospital Emergency Care• The Brain Trauma Foundation. Early indicators of Prognosis in Severe Traumatic Brain Injury.• The Brain Trauma Foundation. Surgical Management of TBI Author Group.• NICE clinical guideline 56. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. http://www.nice.org.uk/CG56• Clinical Neuroanatomy for Medical Students , Richard S. Snell.