Traumatic Brain Injury :

Emergency Aspects

Handoyo Pramusinto
Dept. of Surgery, Faculty of Medicine , UGM

Learning Objectives Week 4

1. To identify emergencies conditions in consciousness dis.
2. To make systematical Ax,Px with do no harm
3. To choose laboratory and radiological examination
4. To manage patient with emergency in consciousness dis.
5. To evaluate the progress and refer the patient safely

References
Advanced Traumatic Life Support (ATLS ),
American College of Surgeon, 2007
Brain, Contusion
In //emedicine.medscape.com/article/337782overview
Closed Head Trauma
In //emedicine.medscape.com/article/251834overview
Concise Neurosurgery,
Emil Pastztor (ed), S.Karger, Sydney, 1980
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References
Critical Care, P. Murphy (ed), Science Press,
2000
Fundamental Critical Care Support,
Course Syllabus,
Society of Critical Care Medicine, 2000
Initial Management of Head Injury,
Selladurai B. And Reilly P., The Mc Graw Hill,
2007
Moderate and Severe Traumatic Brain
Injury in adult, TheLancet.com, 2009
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References
Neuroanatomy, Fitz Gerald, Bailliere Tindall,
London, 1992
Trauma, A Scientific Basis for Care,
Kaya E. And Gosling P. ( eds ), Arnold,London,
2000

TRAUMA,
is the single largest killer of youth
A large number die from head injury
A number are preventable,
by prompt decisive action in the GOLDEN HOUR,
the first few minutes to an hour after trauma

Rajamani SS, Essential Practice of Neurosurgery, 2010

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Please remember about :

Anatomy
scalp, skull, meninges, brain, CSF, tentorium
Physiology
intracranial pressure, cerebral perfusion pressure,
Monro-Kellie doctrin, cerebral blood flow

Clinical Case

10

 Motorcycle vs Pickup
Truck
Truck traveling 40 mph,
Cycle speed ?
30 y/o male w/o helmet
Truck has no damage

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 Opens eyes to loud

verbal stimuli
Localizes painful stimuli
Confused verbal
response to questions
Airway is open and clear
RR=32, chest
expansion, R. wall
bruising
Strong radial pulses, no
major bleeding
Skin pale, moist, cool
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What the problems

How to managed this case

?
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Prehospital Management Protocols

Principles
1.
2.
3.
4.
5.
6.

Avoid hypoxia and hypotension

Protect the spinal cord in unstable spinal injury
Evaluate neurological function
Recognition of other major injuries
Pain relief and sedation
Triage and transport to the most appropriate
facility for further management
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Blood pressure &

Oxygenation

Hypotension ( systole < 90 mmHg )

Hypoxia ( Pa O2 < 60 mmHg, saturation O2 < 90 % )
should be avoided and
correctly immediate if possible

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Cushings Triad
Sign of increased intracranial pressure

characterized by:
1.
2.
3.

Hypertension
Bradycardia
Widening pulse pressure

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Three stages
1. Primary survey and resuscitation
2. Stabilisation
3. Transfer of patient

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Primary survey and resuscitation

Short history + initiation of resuscitation protocols
with prioritise airway, breathing and circulation

Rapid assesment of neurological function

1. AVPU scale ( Alert,Verbal, Pain, Unresponsive )
2. GCS ( Glasgow Coma Scale )

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Primary survey and resuscitation

Other immediate measures
1. Control active bleeding
2. Drainage of tension pneumothorax
3. Splint major limb fractures
4. Correction of hypoglycemia

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Stabilisation
Maintain
1. Oxygen saturation > 90%
2. Systolic blood pressure > 90 mm Hg
( for age >16 years )
Monitoring
Vitas signs,pulse oxymetry, end tidal CO2, GCS, pupil
For patient who show neurological deterioration
Endotracheal intubation

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Management in the E D
The Goals
1. Provide effective resuscitation
2. Evaluate severity of the head injury
3. Initiate management of extracranial injury

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Protocols
1. Initial Triage
2. Primary Survey and Resuscitation
3. Secondary Survey and Stabilisation
4. Definitive Care Phase
( treat intracranial hypertension )

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Initial Triage
A brief history
A rapid assesment
Vital functions, neurological function

In the hypotensive patient,

search major blood loss
In the intubated patient,
check the position and adequacy
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Primary Survey and Resuscitation

Airway management with cervical spine protection
Breathing and ventilation
Circulation
( volume resuscitation and control of hemorrhage )

Disability ( neurological evaluation )

Monitoring
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Secondary Survey and Stabilisation

Principle objectives
Comprehensive evaluation of head injury
and extracranial injuries
Prioritisation of initial management of head injury
and extracranial injuries

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Radiological Examination
1. X-rays of cervical spine & thorax
2. X-rays of cranium
3. Head CT scan

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Laboratory Tests
1.
2.
3.
4.
5.

CBC
Type and cross match
Coagulation profile
Urinalysis
Arterial Blood Gas

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Position
Optimize head position
30 to 60 degrees from horizontal
Decreases ICP
Be careful in patients with acute ischemic
stroke, as this may compromise perfusion to
ischemic tissue at risk
Neck position - midline

Rosner MJ, Coley IB: Cerebra perfusion, intracranial pressure and head elevation.
J Neurosurg1986;65:636-41.
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Volume, CPP, BP, Seizure Prophylaxis

Euvolemia or mild hypervolemia
Isotonic fluids (NS 0.9 %)
CPP > 60 mm Hg
Particularly in patients with TBI
Limit BP swings
Seizure prophylaxis
Recommended in TBI

Raslan A, Bhardwaj A: cerebral edema and intracranial pressur

In: Torbey MT (Ed): Neurocritical care. New York, NY: Cambridge University Pres
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2010:11-1

Ventilation and Oxygenation

PaCO2 maintained at levels that support
regional CBF
(35 mmHg)
Controlled hyperventilation
Avoid hypoxemia
MuizelaarJP, Marmarou A, Ward JD, et al: Adverse effects of prolonged hyperventilation
in patients with severe head injury: A randomized clinical trial. J Neurosurg 1991;75:731-9.

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Fever, Glycemia, Nutrition

Normothermia in every patient
Acetaminophen
Cooling devices
Glycemic control
TBI worsening outcomes with hyperglycemia
Improved outcome with adequate but NOT tight
control
Nutrition
ASAP, enteral ideal,
Bruno A, Williams LS, Kent TA: How important is hyperglycemia during acute brain infarction?
Neurologist 2004;10:195-200
Marik P, Varon J: Intensive Insulin Therapy in the ICU: Is it now time to jump off the bandwagon?
Resuscitation. 2007;74:191-193.
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Osmotherapy
Create an osmotic gradient to cause egress of

water from the brain extracellular

compartment into the vasculature, thereby
decreasing intracranial volume and improving
cerebral compliance

Diringer MN, Zazulia AR: Osmotic therapy: fact or fiction? Neurocrit Care 2004;1:219-34.
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Osmotherapy
Mannitol ,

0.25-1.5g/Kg , IV

Maximal effects seen 20-40 min post

administration, repeat q 6 hours, target sOsm

320 mOsm/L

Knaap JM: Hyperosmolar therapy in the treatment of severe head injury in children.
Mannitol and hypertonic saline. AACN Clin Issues 2005; 16:1991-211.
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Hypertonic Saline Solutions

2%, 3%, 7.5%, 10%, 23%
Achieve euvolemia or slight hypervolemia
Via central venous line
1-2 mL/Kg/hr
250 cc bolus may be used in selected patients
Goals:
Increase Na concentration to 145-155 mEq/L
Keep for 48-72 hours

QureshiAi, Suarez JI: use of hypertonic saline solutions in treatment of cerebral edema and
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Intracranial hypertension. Crit Care Med 2000;28:3301-13.

Safety
Mannitol
Can cause hypotension, hemolysis,
hyperkalemia, renal insufficiency, pulmonary
edema
Hypertonic saline
Safety profile better than mannitol
Can cause CNS changes, myelinolysis,
pulmonary edema, electrolyte derangements,
metabolic acidemia, potentiation of bleeding,
hemolysis, rebound hyponatremia

Varon J, Marik PE: The management of head trauma in children.Crit Care Shock. 2002;5:133-1
Schwarz S, Georgiadis D, Aschoff A, Schwab S: Effects of hypertonic (10%) saline in patients w
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raised intracranial pressure after stroke. Stroke
2002;33:136

Prescription (Do)
(Do)
Prescription
1. Maintain mean BP > 90 mm Hg
2. Maintain PaCO between 25 - 35
mm Hg
3. Use isotonic solution for
euvolemia
4. Frequent neurologic exams
5. Liberal use of CT scans
6. Early neurosurgical consult

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Proscription (Don,t)
(Don,t)
Proscription
Allow patient to become

hypotensive
Over-aggressively hyperventilate
Use hypotonic IV fluids
Use long acting paralytics
Paralyze before performing
complete exam
Depend on clinical exam alone

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Thank you
for your attention

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