Scott G Sagraves, MD

Professor, UMKC
Trauma Medical Director, Saint Lukes Hospital
No financial relationships creating a conflict of
interest to report
Define the anatomy and physiology of
Traumatic Brain Injury (TBI)

Explain the concept of the Monroe-Kellie
Doctrine

Interpret the Brain Trauma Foundation
guidelines for EMS treatment of TBI
Worldwide, TBI is the leading cause of death
& permanent disability
Annually,
>50,000 die
230,000 hospitalized
Trimodal age distribution; < 5, 15-24, > 70

50% mortality within the first TWO hours
AIRWAY & C-spine Control
BREATHING
CIRCULATION & Bleeding Control
DISABILITY - Neurologic Assessment
EXPOSURE
Transient respiratory arrest after TBI

Inability to protect airway with GCS 8

Early intubation for adequate ventilation and
oxygenation
*

Obtain a brief neurologic exam prior to
sedation/intubation
Pre-Hospital Intubation (PHI)is Associated
with an Increased Mortality After TBI
2549 patients analyzed
PHI vs. non-PHI
Mortality 90.2% vs. 12.4%

PHI in isolated, moderate-severe TBI patients
in associated with a nearly 5-fold increase
in mortality.
Bukur M, Kurtovic S, Berry C, et al. J Surg Res 170, e117-e121. 2011
Paralytics are not recommended in the urban
EMS setting for airway management
Airway clearance/establishment to prevent
hypoxia
If using RSI/DAI in the field, monitor:
BP
SpO
2
EtCO
2
Consider the following:
BVM with nasal or oral airway
Rescue airway (e.g. Combitube

, King Airway

)
Transient respiratory arrest after TBI

Inability to protect airway with GCS 8

Early intubation for adequate ventilation and
oxygenation
*

Obtain a brief neurologic exam prior to
sedation/intubation
EMS Assessment
Continuous monitoring for hypoxia
Goal: SpO
2
> 90%

SpO
2
> 90%:
Mortality 14%; Morbidity 3%
SpO
2
60 89%
Mortality 27%; Morbidity 27%
SpO
2
< 60%
Mortality 50%; Morbidity 50%
Hypoxemia is damaging to injured brain, provide
100% oxygen

Ventilate at a normal rate
EtCO
2
goal: 35-40 mmHg
Vt: 6-7 cc/kg and rate 10 breaths/min

Hyperventilation is a rescue maneuver and is
utilized for brief periods with continuous EtCO
2

monitoring
EtCO
2
< 35 should be avoided for extended periods of
time
Hypotension is almost never due to brain
injury or hypovolemia from brain
hemorrhage.

Exsanguination can occur from scalp
laceration

Hypotension (SBP < 90 for 5 min)
doubles brain injury mortality (60% vs. 27%)
additional hypoxia increase mortality to 75%
Goal:
Maintain SBP > 90 mm Hg; MAP > 65
Treatment
Correct hypotension with isotonic fluids
0.9% Normal Saline
Lactated Ringers (LR)

Consider hypertonic saline (3%) if GCS < 8
250 mL 500 mL bolus
EYES OPEN
4 Spontaneously
3 To Verbal Command
2 To Pain
1 No Response

BEST VERBAL RESPONSE
5 Oriented and Converses
4 Disoriented and Converses
3 Inappropriate Words
2 Incomprehensible Sounds
1 No response

BEST MOTOR RESPONSE
6 Obeys
5 Localizes to Pain
4 Flexion Withdrawal
3 Decorticate posturing
2 Decerebrate posturing
1 No Response
Glasgow Coma Score
Mild GCS 14-15 80%

Moderate GCS 9-13 10%

Severe GCS 3-8 10%
Causes 65% of mortality in MVC
In hospital mortality about 30%
Full neurologic recovery rare
Damage to the brain caused by the
initial insult

Only prevention will decrease this
Seatbelts
helmets

EMS goal to prevent secondary injury
Assess for cerebral herniation
Dilated, non-reactive pupils
Asymmetric pupils
Posturing motor exam
Progressive neurologic deterioration

Pupil exam
First rule out orbital trauma
Check after resuscitated/stable
Unilateral or bilateral dilated pupils
Asymmetry
Fixed and non-responsive
Pain Control
No scientific evidence improves outcomes
Opiates/Ketamine may INCREASE ICP
Mannitol
Osmotic diuretic
1 gram/kg for signs of herniation
Hypoglycemia
Assess for using finger stick
Correct hypoglycemia
EMS system with goal the right patient to
the right place in the right amount of time
Strategies
Limit pre-hospital time
Transport vehicle quickest means to closest center
Transport to facility which has:
CT scan capabilities
ICP monitoring
Neurosurgical Care

Usually bleeding from
Middle Meningeal
Artery
Lucid interval
Lens shaped from
pushing the dura off
the skull
Surgery to remove
mass
Usually bleeding from
bridging veins
Concave shape
follows skull
Surgery to remove
mass effect
Associated
underlying brain
contusion
Which would you rather have?
Bleeding in
subarachnoid space

Trauma or ruptured
cerebral aneurysm

Layers in the sulci all
around the brain

May induce
vasospasm, ischemia,
or seizures
Blood in the tissue of
the brain

Diffuse axonal injury
Shear injury to axons.
Terrible prognosis

May require surgery
to remove large clot
or large amount of
damaged brain
The Monroe-Kellie Doctrine
Increased volume in a
closed space results
in either increased
pressure in the space
or loss of some
content of the space.

Describes the natural
history of intracranial
injury (early 1700s)
Brain
Blood
Cerebrospinal
Fluid
Small to moderate
mass effect is
compensated by
decreased CSF and
decreased blood
volume due to
venous compression

Normal ICP
Brain
Blood
Cerebrospinal
Fluid
Mass
Maximum loss of
CSF and venous
blood

Mass results in
brain compression

Elevated ICP
Brain
Blood
Cerebrospinal Fluid
Mass
Mass causes such
severe compression
that arterial flow is
lost

Very High ICPs

Herniation of brain
tissue

Brain death
Brain
Cerebrospinal Fluid
Mass
Herniation

Uncal herniation (2)
Compression of CN III
Dilated pupil
Decrease level of consciousness
Cushing reflex

Cerebellar herniation (4)
Pushed down foramen
Rapid pulmonary failure



Factors which make brain injury
worse or enlarge area of injury:
Hyperglycemia
Hyponatremia
Hypotension
Hypoxia
Hyperthermia
Hypercarbia
Trauma
GCS 3-8 and abnormal
head CT
GCS 3-8 and normal
head CT but two of the
following: age > 40,
hypotension, posturing

Clinical signs of
increased intracranial
pressure
Flow to the brain is the most important

Perfusion pressure is used instead of flow

CPP = MAP ICP

Normal ICP < 10 cm H2o
Acceptable ICP < 20 cm H2o
Normal CPP > 70 cm H2o
Prevent Secondary Injury

Decrease skull contents

Decrease brain metabolic demand

Improve CPP
The mass is abnormal--
Surgical removal is
optimal

Subdural and Epidural
hematomas

Surgery may not be an
option due to location or
multiple small lesions
Brain
Blood
Cerebrospinal
Fluid
Mass
Ventriculostomy !!!
Brain
Blood
Cerebrospinal Fluid
Mass
Only venous blood can be
drained without causing
ischemia

Raise the head of bed

Keep Head straight

Loosen collar

No Jugular lines

Hyperventilation
Brain
Blood
Cerebrospinal
Fluid
Mass
Osmolar therapy--
increased blood
osmolarity decreases
brain fluid

Mannitol -- treatment
only, not prophylactic

Hypertonic Saline
Brain
Blood
Cerebrospinal
Fluid
Mass
Analgesia

Sedation

Paralysis

Cooling

Pentobarbital Coma
ICP should be controlled first, if abnormal

If not controlled, increased MAP will provide
perfusion to the brain despite high ICP
{Cushings Reflex}

Usually use Neosynephrine
Has been used as initial management in past.

Works by causing hypocarbic vasoconstriction
of cerebral blood vessels

DECREASES CEREBRAL BLOOD FLOW

Works only for a short time
Should be used as last ditch therapy
Try to keep pCO2 normal.

Treat Surgical lesions

Prevent secondary injury

Enhance venous drainage

Provide sedation and analgesia

Drain CSF if ventriculostomy is available

Maximize Osmolar therapy


Airway protection?

Hyperventilation??

Head elevation with C-spine control

***Maintenance of blood pressure***
Permissive hypotension not applicable

Osmotic diuresis vs. 3% Saline

Seizure prophylaxis???
Steroid Administration

Furosemide Administration

Hemoglobin Level

Hypothermia

Anticonvulsant Therapy
Never
Theoretical
> 10 g/dL
Difficult
Recommended
10-15% of severe head injuries will develop
intractable elevated ICP
Mortality 84-100%
Treatment
Paralysis
Pressors to enhance MAP
Intermittent hyperventilation
Pentobarbital coma
Drastic measures . . . . . .
Remember what the dormouse said:
Feed your Head. Feed your Head.
--Jefferson
Airplane