Guidelines for prehospital management of traumatic brain injury

Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury

OBJECTIVE

To evaluate the usefulness of early transcranial Doppler ultrasound (TCD) goal-directed therapy after severe traumatic brain injury initiated before invasive cerebral monitoring is available.

DESIGN

Prospective, observational clinical study.

SETTING

Surgical intensive care unit, university hospital.

PATIENTS AND PARTICIPANTS

Twenty-four severely brain-injured patients.

INTERVENTIONS

All patients had TCD measurements immediately on admission (T0) and when invasive cerebral monitoring was available (T1). TCD was considered abnormal when two out of three measured values were outside the following limits: Vm<30 cm/s, Vd<20 cm/s, PI > 1.4. When admission TCD was abnormal, attending physicians modified treatment to increase cerebral perfusion pressure.

MEASUREMENTS AND RESULTS

Admission TCD was performed 18+/-11 min (T0) after admission, whereas cerebral invasive monitoring was available 242+/-116 min (T1) after admission. At T0, 11 (46%) patients had abnormal TCD values (group 1) and 13 had normal TCD values (group 2); mean arterial pressure was comparable between groups. All group 1 patients received mannitol and/or norepinephrine. At T1, mean arterial pressure was increased compared to admission in group 1 (105+/-17 mmHg vs. 89+/-15 mmHg, p<0.05) and only two patients had still an abnormal TCD. Although group 1 patients had higher intracranial pressure than those of group 2 (32+/-13 mmHg vs. 22+/-10 mmHg, p<0.01), both cerebral perfusion pressure and jugular venous oxygen saturation were comparable between the groups.

CONCLUSIONS

The use of TCD at hospital admission allows identification of severely brain-injured patients with brain hypoperfusion. In such high-risk patients, early TCD goal-directed therapy can restore normal cerebral perfusion and might then potentially help in reducing the extent of secondary brain injury.

Care of Central Nervous System Injuries

The primary method of improving outcome from traumatic brain injury is through avoiding secondary insults to the injured brain. Although surgery is important, most management is critical care. Evidence-based guidelines continue to be developed to assist in directing care. With modern monitoring systems, a physiologic-based approach is increasingly applicable, allowing focused treatment for intracranial hypertension and ischemia. It is important to balance and integrate the care of the injured brain into the overall care of the polytrauma patient.

Effect of pre-hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury

BACKGROUND

The role of pre-hospital trauma care and the effect of pre-hospital rapid sequence intubation (RSI) on patient outcome are still not clear. This study evaluated the impact of pre-hospital trauma care by emergency physicians (EP) on mortality from severe traumatic brain injury (TBI) and a 180-day Glasgow Outcome Scale (GOS).

METHODS

A 48-month parallel non-controlled cohort study compared a group of 64 patients with severe TBI [Glasgow Coma Scale (GCS) < 9; Injury Severity Score (ISS) > 15] who received pre-hospital advanced life support (ALS) with RSI and were transported to the hospital by EPs (EP group), with a group of 60 patients who did not receive pre-hospital ALS with RSI [emergency medical technicians (EMT) group].

RESULTS

There were no significant statistical differences between the groups in age (P= 0.79), mechanism of injury (P= 0.68), gender (P= 0.82), initial GCS (P= 0.63), initial SaO(2) in the field (P= 0.63), initial systolic blood pressure in the field (P= 0.47) and on-scene time (P= 0.41). In the EP group, there was significantly better first hour survival (97% vs. 79%, P= 0.02), first day survival (90% vs. 72%, P= 0.02), better functional outcome (GOS 4-5: 53% vs. 33%, P < 0.01; GOS 2-3: 8% vs. 20%, P < 0.01) and shortened hospitalization time in intensive care unit (ICU) (P= 0.03) and other departments (P= 0.04). In total hospital mortality, we detected no differences between both groups [EP group: 40% (95% CI: 34-45%) vs. EMT group 42% (95% CI: 36-47%, P= 0.76], except in a subgroup of patients with GCS 6-8 where there was significantly lower total hospital mortality in the EP group (24% vs. 78%, P < 0.01).

CONCLUSION

After starting the trauma care system with emergency physicians in our region, there was a decrease in the number of deaths on hospital admission, a reduction in hospital mortality in the GCS group 6-8, a change in the temporal distribution of deaths, an improvement in functional neurological outcome and shortened hospitalization time.

Transfer of intubated patients with traumatic brain injury to Auckland City Hospital

BACKGROUND

Delays in patient transfer to definitive neurosurgical care after traumatic brain injury are important in determining neurological outcome. The efficiency of interhospital transfer of patients to Auckland City Hospital (ACH) was analysed and compared with international standards.

METHODS

The ACH Department of Critical Care Medicine database for the year 2002 was reviewed, with supplementary information obtained from transfer organizations, hospital notes, radiology archives, and operative logbooks.

RESULTS

Thirty-four adult patients with traumatic brain injury and no special reasons for delayed transfer were transported intubated from other hospitals in the North Island of New Zealand. The median time from injury to arrival at ACH was 6.5 h. It took a median 4.4 h for patients to get from initial computed tomographic imaging to ACH. For those requiring evacuation of haematomas, the mean time from arrival at ACH to the start of the operation was 1.4 h. Only 33% of patients from other metropolitan Auckland hospitals, and none from hospitals outside the city, arrived within 4 h from the time of injury.

CONCLUSION

Transfer times for brain trauma patients are currently longer than recommended for optimal neurological outcome. Referring hospitals and transfer organizations should review their systems to identify areas for improvement. Direct admission to theatre needs to be expedited within ACH when required. Triage of all trauma patients in metropolitan Auckland with a Glasgow Coma Scale score of less than 14 to ACH would be likely to improve time to treatment. A mobile acute neurosurgical service based in Auckland that would support general surgeons initiating acute decompressive cranial operations would be likely to reduce time to surgery and improve outcomes for patients admitted to hospitals outside Auckland. The development of a mobile acute neurosurgery service which would complete decompressive procedures started by general surgeons would likely improve trauma outcomes for patients injured outside Auckland.

Santé publique et traumatismes crâniens graves. Aspects épidémiologiques et financiers, structures et filières de soins

The management of persons with traumatic brain injury affects a large spectrum of interventions from acute phase to the hospital discharge and the return to community. The incidence of brain injuries on mortality and morbidity constitutes a serious problem in front of the Health Administration. The traffic accidents remain the main cause but the falls in elderly are increasing. In the both cases preventive measures can be efficiency. In France, each year, there are about 150,000 new cases, 8000 of them will be dead and 4000 with coma. It is likely that 30,000 persons are living to day with important sequela of a brain injury. The management requires various types of interventions, each of them with specific and specialized techniques. It is necessary to have an overview of the problem and to work together in a comprehensive network. So French Health Ministry has just published an official note to precise some directives and co-ordination of the different interventions.

Medical management of severe traumatic brain injury

This article reviews the current guidelines for the management of patients with severe traumatic brain injury from presentation in the accident and emergency department, through transfer, to specialist treatment in a neurocritical care unit.

Traumatic brain injury in children--clinical implications

Traumatic brain injury (TBI) is the leading cause of death in childhood; however only very few studies focusing on the specific pathophysiology and treatment have been published to date. Head trauma is more likely in young children than in adults given the same deceleration of the body due to their large and heavy heads and weak cervical ligaments and muscles. Resulting brain injury is more severe due to their thin, pliable skulls and the yet unfused sutures. Accordingly, children below the age of 4 years have lower chances of a full recovery after severe TBI, although in general, neurologic recovery after severe brain injury in children is better than in adults. The time course of brain injury can be divided into two steps: primary and secondary injury. Primary brain injury exclusively results from the initial impact. In contrast, adverse physiologic conditions during recovery after head trauma may account for additional brain damage, which is then referred to as secondary brain injury. As primary brain injury can only be influenced by preventive measures, all therapeutic efforts during the post-injury period focus on the reduction of secondary injury to the traumatized brain. Several mechanisms have been identified to be involved in the development of post-traumatic secondary brain injury, which render the rationale for the key treatment strategies. Three evidence based measures are of critical importance to prevent or minimize secondary brain injury: (1) avoid hypoxemia, (2) avoid post-traumatic arterial hypotension, and (3) refer the traumatized child to an experienced trauma team at a center that provides the availability of special equipment, e.g. for surgical procedures and airway management, for this age group. For several other therapeutical means, e.g. hypothermia or specific surgical interventions, clinical evidence to date is insufficient to allow recommendation as rescue treatment for children at risk of severe neurological sequelae following TBI. This review discusses the clinical implication of pathophysiologic mechanisms of TBI in the developing brain according to the recent literature and current guidelines. It follows the clinical approach to a head injured child, that can be divided into three phases, i.e. initial assessment and stabilization, followed by first tier, and if necessary second tier therapeutic interventions to assure adequate oxygenation and perfusion of the brain.

[Shock trauma room management of the multiple-traumatized patient with skull-brain injuries. A systematic review of the literature]

This overview reviews the literature on multiply injured patients with traumatic brain injuries. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).A detailed analysis of the literature of traumatic brain injuries has been elaborated by the Brain Trauma Foundation and has been published in the World Wide Web (http://www2.braintrauma.org/). The following procedures should be performed in the emergency room for multiply injured patients with traumatic brain injuries: (1) recording of precise history to identify risk factors for severe traumatic brain injury, (2) measurement of the Glasgow Coma Scale (GCS), pupillary reflex, and mean arterial pressure, (3) diagnostic evaluation with a CT scan, and (4) rapid surgical decompression if indicated.

[Preclinical management of multiple trauma]

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Traumatic injury in the developing brain–effects of hypothermia

Little is known about the underlying mechanisms of head trauma in the developing brains, despite considerable social and economic impact following such injuries. Age has been shown to substantially influence morbidity and mortality. Children younger than 4 years of age had worse cognitive, motor, and brain atrophy outcomes than children 6 years of age and older. Younger children tend to more frequently suffer from diffuse cerebral swelling compared to adults. Typical autoptic findings also include axonal injury and ischemic neurodegeneration. These differences impact not only the primary response of the brain to injury but the secondary response as well. The complexity of damaging mechanisms in traumatic brain injury contributes to the problem of determining effective therapy. As an alternative/ adjunct to pharmacological approaches, hypothermia has been shown to be cerebroprotective in traumatized adult brains. Although a large number of animal studies have shown protective effects of hypothermia in a variety of damaging mechanisms after TBI, little data exist for young, developing brains. The injury mechanisms of TBI in the immature, effects of hypothermia following resuscitation on adult and immature traumatized brains, and some possible mechanisms of action of hypothermia in the immature traumatized brain are discussed in this review.

Secondary injuries in brain trauma: effects of hypothermia

Hypothermia has been shown to be cerebroprotective in traumatized brains. Although a large number of traumatic brain injury (TBI) studies in animals have shown that hypothermia is effective in suppressing a variety of damaging mechanisms, clinical investigations have shown less consistent results. The complexity of damaging mechanisms in human TBI may contribute to these discrepancies. In particular, secondary injuries such as hypotension and hypoxemia may promote poor outcome. However, few experimental TBI studies have employed complex models that included such secondary injuries to clarify the efficacy of hypothermia. This review discusses the effects of hypothermia in various TBI models addressing primary and acute secondary injuries. Included are recently published clinical data using hypothermia as a therapeutic tool for preventing or reducing the detrimental posttraumatic secondary injuries and neurobehavioral deficits. Also discussed are recent successful applications of hypothermia from outside the TBI realm. Based on all available data, some general considerations for the application of hypothermia in TBI patients are given.

Osmole gap in neurologic-neurosurgical intensive care unit: Its normal value, calculation, and relationship with mannitol serum concentrations

OBJECTIVE

To determine a) if the admission osmole gap, the difference between osmolality and osmolarity, is the same in the neurologic-neurosurgical intensive care unit (NNICU) population as in healthy controls; b) which of 11 osmole gap formulas, or osmolality, correlates best with mannitol serum concentrations; c) whether osmole gap correction for plasma water content improves this correlation; and d) whether the osmole gap can predict mannitol serum concentrations.

DESIGN

Prospectively collected data.

SETTINGS

NNICU of a tertiary teaching hospital.

SUBJECTS

Ten NNICU patients on mannitol and eight not on mannitol, and 95 healthy controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared the admission osmole gap between all 18 NNICU patients and healthy controls and the correlation between osmole gap or osmolality and mannitol serum concentrations in ten NNICU patients while receiving mannitol. The osmole gap was calculated using 11 osmolarity formulas (six corrected for plasma water content). Student's t-test was used to compare the mean osmole gap between control and patient groups.We found that the mean osmole gap in healthy subjects and NNICU patients was not different. There were no statistically significant differences between any of the 11 osmole gap formulas and the correlation of osmole gap with serum mannitol concentrations; the highest R =.80, with formula 4, 1.86 (sodium + potassium) + (blood urea nitrogen/2.8) + (glucose/18) + 10, requires the least laboratory measurements. Osmolality had the lowest correlation with mannitol concentration (R =.60), significantly lower than any of the osmole gap calculations. Plasma water content correction did not improve this correlation. The osmole gap-mannitol serum concentrations relationship is 1 to 0.81, not accurate enough to predict specific mannitol serum concentrations.

CONCLUSIONS

The osmole gap correlates better with mannitol serum concentrations than osmolality, and although it cannot predict a specific mannitol serum concentration, a normal osmole gap concentration, as we find at trough times, indicates sufficient clearance for a new mannitol dose.

Management of brain and spine injuries

For both SCI and TBI, physicians are unable to affect reversal of the cellular injuries suffered at the time of trauma directly. Unfortunately, understanding such processes is just on the horizon. Physicians do, however, have significant influence on recovery through the avoidance of secondary insults to the injured nervous system. In keeping with trauma in general, the mechanism for this is focused and coordinated multi-disciplinary care originating at the earliest contact and continuing through acute care. Aggressive and pre-emptive attention to the ABC(D)s with attention to the needs of the injured nervous system, appropriate monitoring in all patients, meticulous medical management, and prompt surgical intervention when indicated have made marked improvements in outcome, particularly in TBI. Focusing on the basics and strict attention to detail appear to be the major roles played in the care of CNS trauma.

Critical decision making in severe head injury management

The management of severe head injury (SHI) remains a major challenge not only for neurosurgeons but also for all other health professionals involved in the care of trauma patients. Any trauma patient with SHI is at risk of further neurological deterioration if appropriate measures are not instituted from the start of his or her treatment. Secondary insults due to ischaemic, hypotensive, and metabolic or other causes are still common, even in the most advanced neurocritical care settings. Management controversies are widespread and few decision options can be supported by Class I evidence. This article attempts to provide an up-to-date review of the published recommendations that could help health professionals in their management of SHI.