EM · Traumatic brain injury
Traumatic brain injury
The traumatic brain injury from the primary impact through the preventable secondary injury, the GCS severity classification, the emergency management that protects the brain from hypoxia, hypotension and raised intracranial pressure, the Canadian CT Head Rule, the osmolar therapy (hypertonic saline and mannitol), the ICP staircase, the corticosteroid evidence (harmful), the decompressive craniectomy evidence (DECRA and RESCUEicp), the BEST-TRIP, POLAR and prehospital hypertonic saline trials, the specific injuries (extradural, subdural, diffuse axonal) and the neurosurgical referral.
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Target exams
Red flags
- Early hypotension (SBP below 90) doubled mortality after severe TBI (55% versus 27%) — maintain the blood pressure
- Corticosteroids are harmful in traumatic brain injury and must not be given
- The GCS of 8 or below is the indication for a definitive airway
- The unilateral fixed dilated pupil with a falling GCS is the herniation syndrome — give the osmolar therapy and call the neurosurgeon
- The extradural haematoma with the lucid interval needs the urgent surgical evacuation — the window is narrow
- Routine hyperventilation is harmful — reserve it as a temporising measure for the impending herniation only
- Prophylactic hypothermia does not improve outcome after severe TBI (the POLAR trial) — do not cool the head-injured patient for neuroprotection alone
Meet the patient
A 24-year-old motorcyclist arrives after a high-speed crash. He was talking at the scene; in the resus bay he opens his eyes to pain, grunts only, and withdraws to a central stimulus — GCS 7. His left pupil is 6 mm and fixed, his systolic is 84, saturations 88 per cent on a non-rebreather. The registrar reaches for the ventilator dials.[5][7]
The three questions that decide his next thirty minutes are the three that decide every severe TBI: is his airway and oxygenation secure, is his blood pressure holding, and is that pupil telling me the brain is herniating? Hold those three and every section below slots into place.[5]
References17ShowHide
- [1]Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial Lancet, 2004.PMID 15474134
- [2]Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury N Engl J Med, 2011.PMID 21434843
- [3]Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension N Engl J Med, 2016.PMID 27602507
- [4]Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale Lancet, 1974.PMID 4136544
- [5]Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury J Trauma, 1993.PMID 8459458
- [6]Chesnut RM, Marshall SB, Piek J, et al. Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank Acta Neurochir Suppl (Wien), 1993.PMID 8310858
- [7]Manley G, Knudson MM, Morabito D, et al. Hypotension, hypoxia, and head injury: frequency, duration, and consequences Arch Surg, 2001.PMID 11585502
- [8]Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in traumatic brain injury N Engl J Med, 2012.PMID 23234472
- [9]Cooper DJ, Nichol AD, Bailey M, et al. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial JAMA, 2018.PMID 30357266
- [10]Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial JAMA, 2004.PMID 15026402
- [11]Temkin NR, Dikmen SS, Wilensky AJ, et al. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures N Engl J Med, 1990.PMID 2115976
- [12]Perel P, Arango M, Clayton T, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients BMJ, 2008.PMID 18270239
- [13]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet, 2001.PMID 11356436
- [14]Tatro HA, McMillen JC, Hamilton LA, et al. 23.4% Sodium Chloride Versus Mannitol for the Reduction of Intracranial Pressure in Patients With Traumatic Brain Injury: A Single-Center Retrospective Cohort Study Ann Pharmacother, 2021.PMID 33345546
- [15]Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas Neurosurgery, 2006.PMID 16710967
- [16]Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial J Neurosurg, 1991.PMID 1919695
- [17]Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas Neurosurgery, 2006.PMID 16710968