Chapter 113. Management of Traumatic Brain Injury

• GCS < 9 or a motor scale < 5 = severe traumatic brain injury
• 9 < GCS ≤ 13: “moderate” but beware! Treat like a severe traumatic brain injury until proved otherwise
• GCS 14–15: minor head injury
• Beware of “talk-and-deteriorate” patients, whose GCS drops within 48 hours. Usually subdural or extra-dural hematoma

Airway

• C-collar until C-spine “cleared” (see trauma chapter)
• Tracheal intubation (in-line stabilization, or even fiberoptic)
  • Unclear whether prehospital intubation improves outcome
• Avoid
  • Decreases in MAP during intubation: use RSI with succinylcholine and ketamine or etomidate. Control MAP strictly. Use ephedrine or norepinephrine if necessary
  • Also avoid large increases in MAP during intubation: topical lidocaine, “soft hands”, IV esmolol if needed

Breathing

• Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg

Circulation

• Insert A-line
• Bring MAP > 80 mm Hg with isotonic crystalloids (fluid will not increase ICP in a hypotensive TBI patient)
• If needed, initiate norepinephrine infusion through a CVL
• Bring Hb > 8 g/dL
• If severe hemorrhage due to other lesions, emergent surgical hemostasis might be necessary

Neuro

• Sedation-analgesia by midazolam (also prevents initial seizures) and opioids as infusion
• Emergent CT-scan without contrast; neurosurgery involvement depending on results
• Fixed dilated pupil (uni- or bilateral) = emergency, incipient herniation
  • Neurosurgical consult STAT
  • Acute hyperventilation to PaCO2 of 25 mm Hg
  • Mannitol 20% 2 mL/kg in 10 minutes IV or 7.5% hypertonic saline (HSS) 125 mL IV en route to CT-scan
  • If the pupils are still fixed and dilated, repeat mannitol 20% 4 mL/kg
• Patient on warfarin
  • Give prothrombin complex concentrate (PCC 1 mL/kg) or 25 IU/kg factor IX
  • Give Vitamin K 10 mg IV
• If possible, perform transcranial Doppler (TCD) of MCA
  • Normal values: PI < 1.4 and Vd (diastolic velocity) > 20 cm/s
  • If abnormal, consider increasing MAP and Hb, administering mannitol or HSS

• Immediately if GCS < 15 or GCS = 15 but associated injuries or patient on warfarin
• Delayed at 6 hours after the trauma if GCS 15 with initial loss of consciousness
• Repeat CT-scan if any neurological deterioration
• Repeat CT-scan after 6 hours if normal initially (in 20% of patients with initially normal CT scans, the repeat scan performed beyond the 6th hour is abnormal)

• Prevent secondary injury (ischemic, metabolic, excitatory neurotransmitters, reperfusion)
• Maintain a cerebral perfusion pressure above 60 mm Hg (CPP = MAP − ICP)
  • Monitor ICP if possible; see Chapter 98
• Maintain normocapnia
• Maintain normal osmolarity (290–300 mmol/l). Avoid dextrose or hypotonic fluids
• Seizure prophylaxis: fosphenytoin 13–18 phenytoin equivalents/kg
• Depending on underlying lesion:
  • Neurosurgery if indicated (extra-dural/subdural hematoma, ventriculostomy, craniectomy if uncontrollable increase in ICP)
  • Factor VIIa if persistent intra-cranial bleeding; controversial, very expensive

• GCS 15 without warfarin, loss of consciousness or associated injury: no CT-scan, send home with monitoring instruction sheet
• GCS 15 with ...