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Traumatic brain injury
This document provides guidelines for the assessment and management of head injuries. It outlines the steps for initial assessment including the ABCs (airway, breathing, circulation), indications for intubation and ventilation, and neurological assessment using the GCS. It also discusses indications for CT scanning, referral to hospital or neurosurgery. Key principles of management include maintaining cerebral perfusion pressure, avoiding hypoxia and reducing intracranial pressure through various means. Surgical intervention may be indicated for certain types or sizes of brain injuries or deterioration in condition.
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Traumatic brain injury
- 1.
- 2. ACUTE MANAGEMENT Resuscitation BTLS/ATLS APLS ASSESSMENT
- 3. A IRWAY B REATHING CIRCULATION
- 4.
- 5. Maintain SPO2 >90% Maintain PaO2 > 60mmHg
- 6. When do youintubate?
- 7. Indication for intubation GCS ≤ 8 Loss of protective laryngeal Unable to maintain airway reflexes Unstable facial bone # Bleeding into mouth Seizures Ventilatory insufficiency Spontaneous hyperventilation Irregular respiration
- 8.
- 9. Maintain PCO2 35-40mmHg Obtain CXR ASAP Check ABG
- 10.
- 11. Prevent hypotension Aim SBP> 90mmHg Resuscitation with isotonic cystalloid Inotropes (adrenalin) if needed
- 12. Mortality rate 2.5 x Hypotension 2x + Hypoxia Hypotension Normal Traumatic Coma Data Bank study
- 13.
- 15. Opens their eyeswhen you say their name, and speaks to you in words that make no sense. When you apply pressure on their nail bed, they move their arm away. 10 - M4 V3 E3
- 16. Moves hand towardshead when you apply pressure above the eye socket. They are disoriented but able to form sentences. They open their eyes in response to speech. 12 - M5 V4 E3
- 17. Spontaneously looks around.When you speak to the patient, they can tell you who they are, where they are and why, and the date, and obey simple commands. 15 - M6 V5 E4
- 18. Adult, can obeysimple commands and opens their eyes when they hear you speak. They can talk to you in sentences and seem a little confused and unsure of where they are. 13 - M6 V4 E3
- 19. Indications For Referralto HOSPITAL
- 20. Indications for Referralto Hospital •GCS<15 at initial assessment for two hours and refer if GCS score remains<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 or ears,haemotympanum, boggy haematoma, post auricular or periorbital bruising) •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.
- 21.
- 22. Indications for CT-Scan •eyeopening only to pain or not conversing (GCS 12/15 or less) •ƒ confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to improve 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 penetrating injuries •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.
- 23. When to discusswith a Neurosurgeon
- 24. A patient witha head injury should be discussed with a neurosurgeon: •When a CT scan in a general hospital shows a recent intracranial lesion •ƒ When a patient fulfils the criteria for CT scanning but facilities are unavailable •ƒ When the patient has clinical features that suggest that specialist neuroscience assessment, monitoring, or management are appropriate, irrespective of the result of any CT scan.
- 25. Head Injury Closed Penetrating head injury head injury Mild Moderate- severe Cerebral concussion
- 26. What is cerebralconcussion? “physiologic injury to the brain without any evidence of structural alteration”
- 28. “Many of thesepatients require only minimal observation after they are assessed carefully, and many do not require radiographic evaluation.”
- 29. Management • Keep NBM • IV Drip all NS • GCS chart • Vital sign monitoring • Analgesia • Manage other injuries
- 30. CPP = MAP – ICP CPP = cerebral perfusion pressure >70mmHg in adult > 60mmHg in children
- 31. CPP = MAP – ICP MAP= Mean Arterial Pressure = DP + 1/3 (SP - DP)
- 32. CPP = MAP – ICP ICP= Intracranial pressure Range 5mmHg (infant) to 15mmHg (adult)
- 33. CEREBRAL BLOOD FLOW 50 150 SYSTOLIC BLOOD PRESSURE Autoregulation is lost in trauma, resulting in a linear relationship of BP to cerebral blood flow
- 34. Monroe Kellie DoctrinePrinciple • 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%
- 35.
- 36. Aim - Preventionof secondary brain insults • Avoid hypotension & maintain CPP • Avoid hypoxia • Decrease ICP • Decrease brain metabolism
- 37. Circulatory Support: MaintainCerebral Perfusion Pressure (50-70mmHg) 6 5 Number of 4 Good Hypotensive Moderate Episodes 3 Severe 2 Vegetative 1 Dead 0 Outcome Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
- 38.
- 39. 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)
- 40.
- 41. Decrease ICP • Promotevenous 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
- 42.
- 43. 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
- 44. Decrease metabolism ofbrain • 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
- 45. • 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
- 46. 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
- 47. 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
- 48. Other surgical interventions •Skull bone elevation – Depressed > thickness of cranium – > 1cm depression – Wound contamination • Decompressive craniectomy
- 49. 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
- 50. • 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
- 51. Conclusion • TBI isa 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
- 52. Reference • The BrainTrauma 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.