NEUROSURGICAL ANAESTHESIA
Traumatic brain injury:
initial resuscitation and
transfer
Michael Puntis
Toby Thomas
Abstract
Traumatic brain injury (TBI) is common and is associated with signifi-
cant morbidity and mortality. The initial resuscitation and management
of patients with TBI is focused on limiting secondary brain injury and
this may be complex in patients with significant injuries to other
organ systems. The transport of critically ill brain-injured patients for
definitive treatment also carries significant risks which must be
managed. This review describes the initial resuscitation and transfer
of head-injured patients.
Keywords Airway management; cervical spine injury; major trauma;
transfer; traumatic brain injury
Royal College of Anaesthetists CPD Matrix: 2A11, 2A02, 2F01, 2F03, 3F00
Introduction
Trauma is the most common cause of death of children and
adults under the age of 45 and most traumatic deaths are a result
of traumatic brain injury (TBI). Half of all patients with severe
TBI also have major extracranial injuries and will therefore
require a balanced approach to resuscitation. All significant in-
juries need to be addressed, especially considering that extra-
cranial injuries have the potential to worsen secondary brain
injury, and isolated brain injuries can cause cardiovascular and
respiratory complications.
Initial resuscitation
Prehospital phase
The prehospital management of TBI will vary depending on the
capabilities of the responders and the available resources; how-
ever, the management priorities remain the same. A rapid
assessment needs to be performed, usually in parallel with early
resuscitation. Life-threatening injuries need to be systematically
identified and treated and the patient must then be packaged and
transported for definitive management.
Michael Puntis MRCS FRCA FFICM is a Clinical Fellow in
Neuroanaesthesia and Neurocritical Care at the National Hospital for
Neurology and Neurosurgery, University College London Hospitals,
UK. Conflicts of interest: none declared.
Toby Thomas FRCA FFICM is a Consultant in Neuroanaesthesia and
Neurocritical Care, National Hospital for Neurology and
Neurosurgery, University College London Hospitals, UK. Conflicts of
interest: none declared.
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Learning Objectives
After reading this article you should understand the:
C initial resuscitation of patients with moderate and severe
traumatic brain injury
C general principles of secondary brain injury prevention
C principles of safe inter-hospital transfer
A number of prehospital interventions can potentially reduce
secondary brain injury. Intubation and ventilation may be per-
formed to control hypoxia, hypercapnia or hypocapnia, or to
facilitate the transfer of agitated and combative casualties. Hae-
morrhage control and the administration of fluids (including
blood products) can improve cerebral oxygen delivery and hy-
pertonic saline can be used to control intracranial pressure (ICP).
TBI can be difficult to manage and can even be difficult to
identify in the prehospital environment. Shock from non-
neurological injuries can impair cerebral oxygen delivery and
mimic TBI. An isolated head injury can also produce a period of
apnoea without significant structural damage (impact brain
apnoea).
Airway and cervical spine
When the patient arrives in the emergency department (ED) an
immediate assessment needs to be made to ensure that the
airway is patent. This may include confirming the position of an
existing airway device, or performing de-novo airway in-
terventions. It may also be necessary to intubate the trachea to
prevent aspiration if the airway reflexes are absent, even if the
airway is patent.
While intubation may be an emergency in the context of
airway obstruction, in other situations there is usually time to
perform a focussed examination to determine the Glasgow Coma
Scale (GCS) score, pupillary size and reactivity and the presence
of signs of spinal cord injury. Following induction of anaesthesia
further clinical assessment will be limited.
If the decision is made to intubate the trachea, it is important
to avoid hypotension, hypoxia or a significant increase in ICP.
Consideration of the patient’s physiological status is usually
more important than individual drug choices. However, in most
situations, ketamine and rocuronium are appropriate for induc-
tion of anaesthesia in TBI and can be used safely for both rapid
sequence intubation and delayed sequence intubation. A fluid
bolus may be required to maintain the systemic blood pressure
during the transition to positive pressure ventilation and pre-
oxygenation and apnoeic insufflation dramatically reduces the
incidence of hypoxia.1
The use of pre-intubation checklists is well established for
prehospital intubation, and can also be used to reduce the risk of
errors in ED intubations.
Cervical spine injuries are relatively rare and are often not
associated with a spinal cord injury. However, some injuries may
be unstable and there is a risk of iatrogenic injury.2 There is some
controversy about cervical spine immobilization, but it is
important to consider the risk of cord injury particularly during
230 Ó 2017 Elsevier Ltd. All rights reserved.
 NEUROSURGICAL ANAESTHESIA
intubation. Manual inline stabilization (MILS) should be used
during laryngoscopy and the use of a gum elastic bougie or video
laryngoscope may help to limit the forces transmitted to the
cervical spine. Rigid cervical collars can potentially cause
adverse effects and should be removed as soon as cervical injury
has been excluded.
Ventilation
Mechanical ventilation will be required if the patient has been
intubated to maintain a patent and protected airway. However,
there may be other indications for ventilation. If the patient is
spontaneously hyperventilating or hypoventilating then me-
chanical ventilation should be used to maintain the pCO2 within
an appropriate range (4.5e5.0 kPa). Hypercapnia causes raised
ICP and hypocapnia causes cerebral vasoconstriction and may
impair oxygen delivery. A ventilator should be used to maintain
a consistent minute volume rather than hand ventilation which
can cause wide variation in pCO2.
Mechanical ventilation may be required for the management
of hypoxaemia associated with lung injuries such as contusions.
Positive end-expiratory pressure (PEEP) may be helpful in
maintaining oxygenation and moderate levels (<12 cmH2O) do
not significantly increase the ICP.
Cardiovascular management
The combination of TBI and major haemorrhage can present a
clinical challenge because of conflicting haemodynamic goals.
Systemic injuries with active bleeding benefit from relative hy-
potension while the haemorrhage is controlled, conversely, iso-
lated brain injuries require an elevated systolic pressure to
maintain adequate cerebral perfusion pressure. The risk of
bleeding and the risk of cerebral ischaemia therefore need to be
balanced. For patients with isolated head injuries the systolic
blood pressure can be targeted to maintain an adequate cerebral
perfusion pressure (CPP). If there is evidence of other injuries
which are actively bleeding, then a lower blood pressure target
may be tolerated but the cut-off is debated (Table 1).
Hypotension should be managed by administering fluids to
restore normovolaemia. For isolated head injuries crystalloid
may be appropriate, but polytrauma will require a combination
of blood and blood products to avoid dilutional coagulopathy.
Significant and ongoing haemorrhage needs to be managed
aggressively and should be controlled before proceeding to the
definitive treatment of brain injuries.
Cardiovascular and respiratory targets in severe
traumatic brain injury (TBI)
Ventilation PaO2 > 11 kPa
PaCO2 4.5e5.0 kPa
Cardiovascular Systolic blood pressure (SBP) >90 mmHg (TBI
and life-threatening haemorrhage)6
SBP >100 mmHg (isolated TBI, age 50e69)7
SBP >110 mmHg (isolated TBI age 15e49
years)7
SBP >110 mmHg (isolated TBI, age >70
years)7
Table 1
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Vasopressors are associated with worsening metabolic
acidosis and should generally be avoided during the initial
resuscitation. However, if hypotension persists and is thought to
be caused by vasodilation, then judicious use of vasoconstrictors
may help maintain adequate cerebral perfusion pressure.
Early administration of tranexamic acid reduces the risk of
death in bleeding trauma patients.3 The safety and effectiveness
of tranexamic acid in the treatment of isolated TBI is currently
being investigated.
Neurological assessment
Many major trauma casualties will be unable to cooperate with a
comprehensive neurological examination, either because they
are intubated and sedated, or because they are confused or
distracted by pain. It is important to perform an examination
before induction of anaesthesia, although only a very brief
assessment is required when the airway needs to be managed
urgently.
During the initial resuscitation the most important parameters
are the GCS score, pupillary size and pupillary response. When
life-threatening injuries have been excluded, a secondary survey
should include a more extensive neurological assessment.
Neurological management
Cerebral oedema and intracranial haematoma formation can
cause an increase in ICP which is associated with increased
mortality.4 Even brief, 5-minute, episodes of raised ICP are
associated with worse outcomes.5
During resuscitation it is important to avoid causing unnec-
essary increases in ICP. Cervical collars and endotracheal tube
ties should not compress the jugular veins, adequate analgesia
and sedation should be administered, and the patient should be
positioned with a 30 elevation of the head of the bed (if car-
diovascular status and other injuries allow).
Patients with a deteriorating GCS score or pupillary changes
suggesting critically raised ICP or imminent herniation may
benefit from the administration of hyperosmolar fluids to reduce
cerebral oedema. The use of mannitol (0.25e1.0 g/kg) is rec-
ommended for the acute treatment of elevated ICP but has never
been subject to a randomized comparison against placebo. Hy-
pertonic saline is an alternative agent which may have advan-
tages in haemorrhagic shock.
Cerebral autoregulation is often impaired in TBI and cerebral
blood flow can become pressure dependent. An increase in ICP
with a subsequent fall in CPP will cause cerebral ischaemia and
should therefore be avoided. If ICP monitoring is available, the
CPP can be calculated and the systemic blood pressure can be
increased to maintain adequate cerebral perfusion.
Imaging
It is important to rapidly identify all significant injuries and
multislice CT scanning has become an important element of
trauma resuscitation. CT is the primary investigation for identi-
fying brain injuries and plain skull or c-spine X-rays and MRI
have no role during the resuscitation phase of major trauma.
All adults with a moderate or severe head injury should
have a CT scan of the head and cervical spine performed
within 60 minutes. Other indications for urgent scanning
include post-traumatic seizures, focal neurological deficit or
231 Ó 2017 Elsevier Ltd. All rights reserved.
 NEUROSURGICAL ANAESTHESIA
more than one episode of vomiting (Box 1). Patients with mild
head injury who have not returned to a GCS score of 15 should
also have a scan within 2 hours to exclude intracranial
pathology.
Repeat imaging may be indicated as brain injury develops,
and is essential following any clinical deterioration or significant
increase in ICP.
Transfer
Trauma networks
Regional trauma networks were developed to provide an orga-
nized system for collaboration between a central major trauma
centre (MTC) and a number of smaller trauma units (TUs) which
deliver care for less complex cases. A third level of local hospitals
provide emergency department services for minor injuries. Spe-
cific triage protocols have been introduced to support decisions
regarding which patients should be taken directly from the scene
to the MTC and consequently all moderate and severe head in-
juries are usually transferred directly from the scene to a MTC
with neurosurgical capabilities. The requirement for secondary
transfer is therefore less common but patients with severe TBI
are still admitted to trauma unit in certain situations. For
example, if the patient has an obstructed airway, has been under-
triaged or self-presents at an ED.
Patients with moderate or severe TBI who have been admitted
to a TU or local hospital will need to be transferred to an MTC for
definitive management of their neurological injury, even if im-
mediate surgical intervention is not required. The urgency of that
transfer will depend on their injuries.
Referral
After performing a primary survey and critical investigations any
patient with injuries which cannot be managed locally should be
referred to the MTC.
The transfer of patients from a TU to an MTC will vary ac-
cording to injury pattern and local policies, but generally, iso-
lated, severe TBI with an abnormal CT should be transferred
immediately to the regional MTC. Patients with extradural or
subdural haematoma with midline shift should also be trans-
ferred immediately. For any emergency, it is important to
confirm if the patient needs to be transferred to the ED or directly
to the operating theatre or angiography suite.
Criteria for performing a CT head scan
C Glasgow Coma Scale (GCS) score < 13 on initial assessment
C GCS < 15 at 2 hours after injury on assessment in the emergency
department
C Suspected open or depressed skull fracture
C Any sign of basal skull fracture
C Post-traumatic seizure
C Focal neurological deficit
C More than one episode of vomiting since the head injury
Head injury: assessment and early management, NICE Clinical
guideline [CG176] Published date: January 2014
Box 1
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Patients with mild or moderate TBI should be discussed with
the regional neurosurgical team for further advice.
Timing of transfers
Although transfer for definitive treatment is often time critical,
the initial resuscitation and stabilization of the patient should be
completed and monitoring established before leaving the ED to
avoid complications during the journey. Even for emergencies
the patient must be transferred safely.
Practicalities
For time-critical transfers it is important to avoid unnecessary,
time-consuming interventions. Often, procedures such as the
insertion of arterial and central venous catheters can be deferred,
especially for short transfers. The immediate priorities are
endotracheal intubation, adequate venous access and ensuring
that the ICP can be managed and the systemic blood pressure can
be maintained. The fundamental physiological aims do not
change when the patient leaves the ED and adequate oxygen
delivery and CPP must be maintained during the transfer.
If other systemic injuries are present, then it may be necessary
to carry additional equipment or to take blood products in the
ambulance. It is essential to have a plan for managing any
deterioration in the patient’s condition.
The transfer team must include an appropriately trained
doctor and another healthcare professional, competent in airway
management and the treatment of trauma. A checklist should be
used to ensure adequate monitoring, equipment, drugs and all
patient records are included. A reliable means of communication
should be available during the transfer and if there are significant
changes in the patient’s condition en-route the MTC consultant
or neurosurgeon must be informed as this may result in the pa-
tient going directly to theatre. A
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