MAJOR TRAUMATIC BRAIN INJURY

Question 1

KEY CONCEPTS

Answer 1

DEFINITION:

Mild: GCS 13-15
Moderate: GCS 9-12
Severe: GCS 3-8

GOALS OF CARE:
Prevent secondary brain insult: correct hypotension and hypoxia

Risk of mortality with hypoxia and hypotension in sTBI: 75%

CT indication for surgical intervention:
Midline shift > 5 mm

Question 2

DDx

Answer 2

Toxidrome
Hypoglycemia
Seizure
Meningitis or encephalitis
Stroke

Question 3

MANAGEMENT

Answer 3

1. AIRWAY / BREATHING

ETT + Ventilation for GCS < 8
OR
highter GCS score and declining

Induction: Ketamine

2. BREATHING

PRIMARY GOAL: PREVENT HYPOXIA

Sp02 > 98%

Target PC02 35-45 mm Hg; end-tidal PC02 (ETC02) 30-40 mm Hg

Do NOT perform prophylactic hyperventilation

Hyperventilate BRIEFLY (pC02 25-30) if evidence of herniation / neurological deterioration

2. CIRCULATION

PRIMARY GOAL: PREVENT HYPOVOLEMIA

i. PREVENT HYPOVOLEMIA
BP TARGET:
SBP > 100 pts 50-69
SBP > 110 pts 15 - 49

Minimize IV Crystalloid Fluid

ii. REVERSE ANTICOAGULATION
Warfarin with elevated INR: Octaplex (PCC) 80mL (2000 U) + 10 mg Vit K IV, hold Warfarin, repeat INR

Rivaroxaban / Apixaban / Edoxaban: Octaplex (PCC) 80mL (2000 U) +/- 10 mg Vit K IV if elevated INR

Heparin: 1 mg Protamine per 100 units of unfractionated Heparin

Dabigatran: idarucizumab 5 g IV
fXa: andexamet, TXA
Thrombocytopenia: platelet transfusion

4. DISABILITY

PRIMARY GOAL: GCS, PUPILS, BEST MOTOR RESPONSE and REDUCE ICP

i. Determine GCS, Pupillary Light Response, Best Motor Response PRIOR to intubation

BEST motor response -> more accurate prognostic indicator than the worst response

Do NOT overlook TBI with confounders like drugs, EtOH, toxins, post-ictal

ii. C-Spine immobilization

iii. Head of bed elevated at 30 degrees

iv. ACUTE ICP
Hypertonic sodium chloride 3% IV at 250 ml over 15 min at 1000 mL/hr for ICP >20 mm Hg (Max 500 mL)
OR
ACUTE DECOMPENSATION:
Mannitol 0.5-1 g/kg IV over 20-30 min

v. Low dose IV narcotics:
25-50 mcg Fentanyl IV

5. SEIZUREPPX:
   Levetiracetam (Keppra) 20-40 mg/kg (max 2500 mg) IV loading dose followed by total loading dose amount given in divided doses q12h for maintenance
6. INVESTIGATIONS
   Hgc
   Coags
   T&C

CT HEAD without contrast: STAT if GCS < 8

Early neurosurgical consultation

MONITOR
Serial neuro exams:
GCS
Pupil Response
Motor Function

Question 4

DOCUMENTATION

Answer 4

1. HPI:
   Age: < 16, >/ 65

Time of injury

Mechanism: pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from > 3 ft OR > 5 stairs

LOC

Retrograde Amnesia to the head injury event (>? 30 min)

Witnessed disorientation

Seizure activity

Vomitting (>/ 2 episodes)

Ask about any other injuries

Meds: Blood thinners

2. PHYSICAL EXAM:

GCS (13-15)

GCS < 15 at 2 hrs post-injury

Complete Trauma Survey

Open or depressed skull fracture

Basilar Skull Fracture: hemotympanum, racoon eyes, battle’s sign, otorrhea / rhinorrhea

CN Exam: PUPIL symmetry and size

CNS Exam

3. APPLY TO THE CANADIAN CT HEAD RULES