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Traumatic brain injury: Learning Objectives

initial resuscitation and After reading this article you should understand the:

transfer C initial resuscitation of patients with moderate and severe

traumatic brain injury
C general principles of secondary brain injury prevention
Michael Puntis
C principles of safe inter-hospital transfer
Toby Thomas

Abstract A number of prehospital interventions can potentially reduce

Traumatic brain injury (TBI) is common and is associated with signifi-
secondary brain injury. Intubation and ventilation may be per-
cant morbidity and mortality. The initial resuscitation and management
formed to control hypoxia, hypercapnia or hypocapnia, or to
of patients with TBI is focused on limiting secondary brain injury and
facilitate the transfer of agitated and combative casualties. Hae-
this may be complex in patients with significant injuries to other
morrhage control and the administration of fluids (including
organ systems. The transport of critically ill brain-injured patients for
blood products) can improve cerebral oxygen delivery and hy-
definitive treatment also carries significant risks which must be
pertonic saline can be used to control intracranial pressure (ICP).
managed. This review describes the initial resuscitation and transfer
TBI can be difficult to manage and can even be difficult to
of head-injured patients.
identify in the prehospital environment. Shock from non-
Keywords Airway management; cervical spine injury; major trauma; neurological injuries can impair cerebral oxygen delivery and
transfer; traumatic brain injury mimic TBI. An isolated head injury can also produce a period of
apnoea without significant structural damage (impact brain
Royal College of Anaesthetists CPD Matrix: 2A11, 2A02, 2F01, 2F03, 3F00

Airway and cervical spine

Introduction When the patient arrives in the emergency department (ED) an
immediate assessment needs to be made to ensure that the
Trauma is the most common cause of death of children and airway is patent. This may include confirming the position of an
adults under the age of 45 and most traumatic deaths are a result existing airway device, or performing de-novo airway in-
of traumatic brain injury (TBI). Half of all patients with severe terventions. It may also be necessary to intubate the trachea to
TBI also have major extracranial injuries and will therefore prevent aspiration if the airway reflexes are absent, even if the
require a balanced approach to resuscitation. All significant in- airway is patent.
juries need to be addressed, especially considering that extra- While intubation may be an emergency in the context of
cranial injuries have the potential to worsen secondary brain airway obstruction, in other situations there is usually time to
injury, and isolated brain injuries can cause cardiovascular and perform a focussed examination to determine the Glasgow Coma
respiratory complications. 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.
Initial resuscitation
If the decision is made to intubate the trachea, it is important
Prehospital phase to avoid hypotension, hypoxia or a significant increase in ICP.
The prehospital management of TBI will vary depending on the Consideration of the patient’s physiological status is usually
capabilities of the responders and the available resources; how- more important than individual drug choices. However, in most
ever, the management priorities remain the same. A rapid situations, ketamine and rocuronium are appropriate for induc-
assessment needs to be performed, usually in parallel with early tion of anaesthesia in TBI and can be used safely for both rapid
resuscitation. Life-threatening injuries need to be systematically sequence intubation and delayed sequence intubation. A fluid
identified and treated and the patient must then be packaged and bolus may be required to maintain the systemic blood pressure
transported for definitive management. 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
Michael Puntis MRCS FRCA FFICM is a Clinical Fellow in
Neuroanaesthesia and Neurocritical Care at the National Hospital for prehospital intubation, and can also be used to reduce the risk of
Neurology and Neurosurgery, University College London Hospitals, errors in ED intubations.
UK. Conflicts of interest: none declared. Cervical spine injuries are relatively rare and are often not
associated with a spinal cord injury. However, some injuries may
Toby Thomas FRCA FFICM is a Consultant in Neuroanaesthesia and
Neurocritical Care, National Hospital for Neurology and be unstable and there is a risk of iatrogenic injury.2 There is some
Neurosurgery, University College London Hospitals, UK. Conflicts of controversy about cervical spine immobilization, but it is
interest: none declared. important to consider the risk of cord injury particularly during

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intubation. Manual inline stabilization (MILS) should be used Vasopressors are associated with worsening metabolic
during laryngoscopy and the use of a gum elastic bougie or video acidosis and should generally be avoided during the initial
laryngoscope may help to limit the forces transmitted to the resuscitation. However, if hypotension persists and is thought to
cervical spine. Rigid cervical collars can potentially cause be caused by vasodilation, then judicious use of vasoconstrictors
adverse effects and should be removed as soon as cervical injury may help maintain adequate cerebral perfusion pressure.
has been excluded. Early administration of tranexamic acid reduces the risk of
death in bleeding trauma patients.3 The safety and effectiveness
Ventilation of tranexamic acid in the treatment of isolated TBI is currently
Mechanical ventilation will be required if the patient has been being investigated.
intubated to maintain a patent and protected airway. However,
there may be other indications for ventilation. If the patient is Neurological assessment
spontaneously hyperventilating or hypoventilating then me- Many major trauma casualties will be unable to cooperate with a
chanical ventilation should be used to maintain the pCO2 within comprehensive neurological examination, either because they
an appropriate range (4.5e5.0 kPa). Hypercapnia causes raised are intubated and sedated, or because they are confused or
ICP and hypocapnia causes cerebral vasoconstriction and may distracted by pain. It is important to perform an examination
impair oxygen delivery. A ventilator should be used to maintain before induction of anaesthesia, although only a very brief
a consistent minute volume rather than hand ventilation which assessment is required when the airway needs to be managed
can cause wide variation in pCO2. urgently.
Mechanical ventilation may be required for the management During the initial resuscitation the most important parameters
of hypoxaemia associated with lung injuries such as contusions. are the GCS score, pupillary size and pupillary response. When
Positive end-expiratory pressure (PEEP) may be helpful in life-threatening injuries have been excluded, a secondary survey
maintaining oxygenation and moderate levels (<12 cmH2O) do should include a more extensive neurological assessment.
not significantly increase the ICP.
Neurological management
Cardiovascular management Cerebral oedema and intracranial haematoma formation can
The combination of TBI and major haemorrhage can present a cause an increase in ICP which is associated with increased
clinical challenge because of conflicting haemodynamic goals. mortality.4 Even brief, 5-minute, episodes of raised ICP are
Systemic injuries with active bleeding benefit from relative hy- associated with worse outcomes.5
potension while the haemorrhage is controlled, conversely, iso- During resuscitation it is important to avoid causing unnec-
lated brain injuries require an elevated systolic pressure to essary increases in ICP. Cervical collars and endotracheal tube
maintain adequate cerebral perfusion pressure. The risk of ties should not compress the jugular veins, adequate analgesia
bleeding and the risk of cerebral ischaemia therefore need to be and sedation should be administered, and the patient should be
balanced. For patients with isolated head injuries the systolic positioned with a 30 elevation of the head of the bed (if car-
blood pressure can be targeted to maintain an adequate cerebral diovascular status and other injuries allow).
perfusion pressure (CPP). If there is evidence of other injuries Patients with a deteriorating GCS score or pupillary changes
which are actively bleeding, then a lower blood pressure target suggesting critically raised ICP or imminent herniation may
may be tolerated but the cut-off is debated (Table 1). benefit from the administration of hyperosmolar fluids to reduce
Hypotension should be managed by administering fluids to cerebral oedema. The use of mannitol (0.25e1.0 g/kg) is rec-
restore normovolaemia. For isolated head injuries crystalloid ommended for the acute treatment of elevated ICP but has never
may be appropriate, but polytrauma will require a combination been subject to a randomized comparison against placebo. Hy-
of blood and blood products to avoid dilutional coagulopathy. pertonic saline is an alternative agent which may have advan-
Significant and ongoing haemorrhage needs to be managed tages in haemorrhagic shock.
aggressively and should be controlled before proceeding to the Cerebral autoregulation is often impaired in TBI and cerebral
definitive treatment of brain injuries. 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
Cardiovascular and respiratory targets in severe CPP can be calculated and the systemic blood pressure can be
traumatic brain injury (TBI) increased to maintain adequate cerebral perfusion.

Ventilation PaO2 > 11 kPa Imaging

PaCO2 4.5e5.0 kPa It is important to rapidly identify all significant injuries and
Cardiovascular Systolic blood pressure (SBP) >90 mmHg (TBI multislice CT scanning has become an important element of
and life-threatening haemorrhage)6 trauma resuscitation. CT is the primary investigation for identi-
SBP >100 mmHg (isolated TBI, age 50e69)7 fying brain injuries and plain skull or c-spine X-rays and MRI
SBP >110 mmHg (isolated TBI age 15e49 have no role during the resuscitation phase of major trauma.
years)7 All adults with a moderate or severe head injury should
SBP >110 mmHg (isolated TBI, age >70 have a CT scan of the head and cervical spine performed
years)7 within 60 minutes. Other indications for urgent scanning
include post-traumatic seizures, focal neurological deficit or
Table 1

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more than one episode of vomiting (Box 1). Patients with mild Patients with mild or moderate TBI should be discussed with
head injury who have not returned to a GCS score of 15 should the regional neurosurgical team for further advice.
also have a scan within 2 hours to exclude intracranial
pathology. Timing of transfers
Repeat imaging may be indicated as brain injury develops, Although transfer for definitive treatment is often time critical,
and is essential following any clinical deterioration or significant the initial resuscitation and stabilization of the patient should be
increase in ICP. completed and monitoring established before leaving the ED to
avoid complications during the journey. Even for emergencies
Transfer the patient must be transferred safely.

Trauma networks Practicalities

Regional trauma networks were developed to provide an orga- For time-critical transfers it is important to avoid unnecessary,
nized system for collaboration between a central major trauma time-consuming interventions. Often, procedures such as the
centre (MTC) and a number of smaller trauma units (TUs) which insertion of arterial and central venous catheters can be deferred,
deliver care for less complex cases. A third level of local hospitals especially for short transfers. The immediate priorities are
provide emergency department services for minor injuries. Spe- endotracheal intubation, adequate venous access and ensuring
cific triage protocols have been introduced to support decisions that the ICP can be managed and the systemic blood pressure can
regarding which patients should be taken directly from the scene be maintained. The fundamental physiological aims do not
to the MTC and consequently all moderate and severe head in- change when the patient leaves the ED and adequate oxygen
juries are usually transferred directly from the scene to a MTC delivery and CPP must be maintained during the transfer.
with neurosurgical capabilities. The requirement for secondary If other systemic injuries are present, then it may be necessary
transfer is therefore less common but patients with severe TBI to carry additional equipment or to take blood products in the
are still admitted to trauma unit in certain situations. For ambulance. It is essential to have a plan for managing any
example, if the patient has an obstructed airway, has been under- deterioration in the patient’s condition.
triaged or self-presents at an ED. The transfer team must include an appropriately trained
Patients with moderate or severe TBI who have been admitted doctor and another healthcare professional, competent in airway
to a TU or local hospital will need to be transferred to an MTC for management and the treatment of trauma. A checklist should be
definitive management of their neurological injury, even if im- used to ensure adequate monitoring, equipment, drugs and all
mediate surgical intervention is not required. The urgency of that patient records are included. A reliable means of communication
transfer will depend on their injuries. should be available during the transfer and if there are significant
changes in the patient’s condition en-route the MTC consultant
Referral or neurosurgeon must be informed as this may result in the pa-
After performing a primary survey and critical investigations any tient going directly to theatre. A
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- REFERENCES
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Box 1

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Downloaded for Prof.Dr.dr. Farid Anfasa Moeloek, SpOG (K) (fmoeloek@gmail.com) at Universitas Indonesia from ClinicalKey.com by Elsevier on January 02, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.