Acute Management of

Traumatic Brain Injury

Dr N. Vairavan
Neurosurgery Unit
Department of Surgery
Faculty of Medicine
University Malaya
 Traumatic Brain Injury
 2% of population/year
 43,000 people/yr
 10 – 15 % severe injury
 65% of mortality due to severe TBI
 Major cause of death and disability among
productive age group
 Major socioeconomic effect on the family,
society and country
Intensive Management Protocols
 Early intubation
 Rapid transportation
 Prompt resuscitation
 Early CT Scan
 Immediate evacuation of intracranial mass
lesion
 Meticulous ICU management
 Prehospital Management
 Transport direct to nearest facility with the
resources to intervene and optimise pt
 Airway
 Breathing
 Circulation
 Cervical Spine Immobilisation
 Supplemental Oxygen/ Endotracheal intubation
 Level III evidence of improved survival

Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival
in patients with severe head injury. Arch Surgery 132: 592- 597, 1997
 Prehospital hypotension (SBP <90), hypoxemia
(SpO2< 90 )
– independent predictors of outcome

Prehospital measurement of GCS, pupillary response

- predictors of outcome

Chestnut RM. Role of secondary brain injury in determining outcome in

severe head injury. J Trauma. 34: 216 – 222, 1993
Baxt WG. Impact of advanced prehospital emergency care on the mortality of
severely brain injure patients. J Trauma. 27:365 -369, 1987
 Prehospital Brain targeted therapy
 Hyperventilation
 Mannitol
 Sedation
 Analgesic
 Paralytic

 Only hyperventilation recommended on Level III

evidence in presence of brain herniation

Raichle M. Hyperventilation and cerebral blood flow. Stroke 3:965 – 972, 1972
Imaging Guidelines
Brain
Imaging Guidelines
Cervical Spine
 Hypotension & Hypoxemia
 ↑ Morbidity & Mortality
 Single episode of SBP < 90 mmHg
 Apneic cyanosis or SpO2 < 90 or PaO2 < 60

 Level III evidence only

 Miller et al ’78, Chestnut et al ’93, Manley et al ’01, Struchen et al ‘01

 ?? Treatment threshold, Optimal resuscitation

protocals, Target values, treatment impact on outcome
 Hyperosmolar Therapy
 Mannitol 0.25 to 1 gm/kg BW
 Single shot – buy time for diagnostic or interventional
procedure – Level III recommendation
 Prolonged therapy – for control of persistently raised
ICP
 Arterial hypotension should be avoided

 ??Infusion vs bolus, Risks of prolonged

administration

 Becker and Vries ’72, Mendelow et al ’85, Eisenberg et al ’88

 Roberts I et al Cochrane Syst RV 2003
 Hyperosmolar Therapy
 Hypertonic Saline
 Reduce ICP without compromising BP, CPP or causing
cerebral vasoconstriction
 Osmotic mobilisation, microcirculatory effect, reduced
leukocyte adhesion
 3% saline 0.1 to 1.0mL/kg BW/ Hr on a sliding scale
 Level III recommendation
 HS bolus infusion - effective adjuvant / alternative to
mannitol
 ??Dose, concentration, method
 Shackford et al ’98, Quereshi et al ‘99
 Prophylactic Hypothermia
 Target cooling 32 -33ºC
 Duration of ≤ 48H
 Rate of rewarming 1ºC /H or slower

 Meta Analysis of 6 RCT

 All cause mortality not different from control group
 46% increased chance of good outcome (GOS 4 or 5)

 Avoid Hyperthermia

 ??Target, duration
 Abiki et al 2000, Jiang et al 2000, Qiu et al 2003
 Infection Prophylaxis
 Periprocedural antibiotics for intubation
 No change in LOS or mortality (1)
 Early tracheostomy
 Reduce mechanical ventilation days
 No change in mortality or nosocomial pneumonia rates (2)
 No support for routine catheter changes to prevent
infection (L-III) (3)
 No support for routine systemic prophylaxis in
ventilated TBI patients (L-III)
 Periprocedural prophylaxis does decrease pneumonia
(L-III)
 1.Poon et al Acta Neur 1998, 2. Sugerman RJ J Trauma 1997, 3. Holloway
et al J Neuro 2000,
 DVT Prophylaxis
 20% pt with TBI develop DVT
 0.38% incidence of PE in TBI pt

 Graduated compression stockings (L-III) (1)

 LMWH used in combination with mechanical prophylaxis (L–
III) (2)
 Lower risk of DVT, no difference in mortality
 Risk of intracranial h’ghe expansion

 ?? Dose, agent, timing of prophylaxis

 1. Black et al Neuro 1986, 2. Gerlach et al Neuro 2003

 Indication for ICP Monitoring
 ICP in all pt with severe TBI ( GCS 3-8) and
abnormal CT scan (L-II)
 ICP in severe TBI and normal CT scan if
 >40 yrs age
 Unilat or bilat posturing
 SBP < 90mmHg
 ICP monitoring allows
 Prediction of outcome and worsening intracranial pathology
 Calculate and manage CPP
 Allow therapeutic CSF drainage in ventricular monitors
 Restrict potentially delterious ICP reduction therapies

 NarayanRK et al J Neuro 1982

 ICP Monitoring Technology
 Ventricular catheter + ext strain gauge
 Parenchymal ICP monitor
 Subarachnoid, subdural, epidural monitors

 Pressure range 0 -100 mmHg

 Accuracy ± 2mm Hg in 0-20 range
 Max error 100% in 20 – 100 range

 Complication – Hemorhage, Malfunction,

Infection

 Lundberg et al Acta Psych 1960, Narayan R et al J

Neurosurg 1982, Stendel R et al Acta Neur 2003
 ICP Threshold
 Treatment should be commenced at ICP > 20 mmHg
(L–II) (1)
 Treatment threshold > 25 without craniectomy and >
15 post craniectomy ( L-II) (2)

 ?? Herniation threshold pressure

 As little as 18mmHg
 ?? ICP interaction with CPP, CBF, Sjo2


1. Marmarou et al J Neuro 1991, 2. Eisenberg et al J Neuro 1988
 CPP Threshold
 Aggressive attempt to maintain CPP > 70mm
should be avoided ( L-II) (1)
 CPP < 50 should be avoided ( L-III) (2)
 Target CPP 50 – 70 mm Hg

 ?? Physiologic endpoint vs clinical endpoint

 1. Robertson et al Crit Care Med 1999, 2. Nordstrom PH et al, Anesthesia

2003
 Brain Oxygen Monitoring and
Threshold
 Jugular venous saturation or brain tissue oxygen
monitoring measure cerebral oxygenation
 SjO2 < 50% (1), PbrO2 < 15mmHg (2) are threshold for
intervention

 Cerebral microdialysis, thermal diffusion probe, transcranial

doppler, near infrared spectroscopy

 1. Robertson CS et al J Neurotrauma 1995 2. Valadka et al 1998

 Analgesic, Sedation, Anesthetic
 Propofol recommended for ICP control
 No improvement in mortality or 6 mth outcome
 High dose propofol produce significant morbidity
 Propofol – rapid onset, short duration of action
 Depress cerebral metabolism and oxygen consumption
 Kelly PF et al J Neuro 1999
 Barbiturates
 Barbiturates
 Cerebral protective alteration in vascular tone and resistance
 Suppression of metabolism
 Inhibition of lipid peroxidation
 Inhibition of excitotoxicity

 Prophylactic barbiturate to induce burst suppression not

recommended (1)
 High dose barbiturate recommended to control elevated ICP
refractory to standard medical and surgical treatment (2)
 Cochrane Systematic Review (2004)
‘No evidence that barbiturate therapy in patients with acute severe head
injury improves outcome’

 1. Ward JD et al J Neuro 1985, 2.Eisenberg HM et al J Neuro 1988,

3.Robert I et al. Cochrane Library 2005
 Nutrition
 Patients should be fed to attain full caloric
replacement by day 7 post injury (1)
 Start gastric or jejunal feed by day 3

 Hyperglycemia should be controlled (2)

 Zinc supplementation may be beneficial (3)

 1. Taylor SJ et al Crit Care Med.1999, 2. Lam AM et al J Neuro 1991,

3.Young B et al J Neurotrauma 1996
 Anti Seizure Prophylaxis
 Prophylactic anticonvulsants are not
recommended for preventing late
posttraumatic seizures (1)
 Anticonvulsants are indicated to decrease
incidence of early PTS (2)

 ?? Benefit vs compication
 1. Manaka S et al J Psych Neur 1992, 2. Temkin N et al N Eng J Med 1990
 Hyperventilation
 Prophylactic hyperventilation ( PaCO2 < 25) is
not recommended (1)
 Hyperventilation may be used as a temporizing
measure to reduce ICP (1)
 Hyperventilation should be avoided in first 24
hrs of injury (3)

 1. Muizellar JP J Neuro 1991, 2. 3. Bouma GJ J Neuro 1992

 Steroids
 Steroids is not recommended for improving
outcome or reducing ICP (1)
 In moderate to severe TBI, high dose methyl
pred is assoc with increased mortality (2)

 1. Alderson P Br Med J 1997, 2. Roberts I MRC CRASH Trial Lancet

2004
 Decompressive Craniectomy
 Removal of a large portion of skull to provide
spacefor brain expansion
 Reduction of refractory ICP due to severe TBI
or malignant MCA infarct
 Observational studies provide L-III evidence
of good outcome (1,2)
 On going L-I trialsmay provide answers (3,4)

 1. Kunze E et al Acta Neuro 1998, 2. Polin RS Neurosurg 1997,

3.Hutchinson PJ RESCUEicp trial, 4. Cooper DJ et al DECRA trial
 GCS<8
CT Brain

Insert ICP Monitor

Maintain CPP
(Age Appropriate)

NO ICP Consider CT
Carefully withdraw
ICP treatment Sedation & Analgesia
Head up 300

NO ICP
Drain CSF if Ventriculostomy
May continue if is present May continue if S. Osm<360
S. Osm<320
NO ICP
Neuromuscular Blockade

Mannitol PRN ICP HTS 3%

Second Tier
Mild Hyperventilation PaCO2 30-35 mm Hg ICP Therapy
NO
 Second Tier Therapy

 ICP despite first tier Rx

Working Ventriculostomy Active EEG?

No contraindication to
Consider lumbar drain Barb

Consider high dose Barb

Salvageable patient

Consider decompressive
Evidence of Hyperemia ? craniectomy Evidence of Ischemia?
No Evidence of Ischemia No evidence of
contraindication
to Hypothermia?
Consider Hyperventilation
To PaCO2 < 30 mm Hg Consider moderate
Consider monitoring CBF, hypothermia
SjO2, AFDO2
 Thank You
for
your kind attention