downloaded from the foundation website: http://www. braintrauma.org. In addition, the American College of Surgeons Trauma Quality Improvement Program (TQIP) published a guideline for managing TBI in 2015. (See ACS TQIP Best Practices in the Management of
Traumatic Brain Injury.)
Even patients with apparently devastating TBI on presentation can realize significant neurological re-
nFIGURE 6-7 CT Scans of Intracranial Hematomas. A. Epidural
hematoma. B. Subdural hematoma. C. Bilateral contusions with hemorrhage. D. Right intraparenchymal hemorrhage with right to left midline shift and associated biventricular hemorrhages.
A
B
C
D
EVIDENCE-BASED TREATMENT GUIDELINES 111
evideNce-bAsed tReAtmeNt
guideliNes
112 CHAPTER 6 n Head Trauma
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covery. Vigorous management and improved under- standing of the pathophysiology of severe head injury, especially the role of hypotension, hypoxia, and cerebral perfusion, have significantly affect- ed patient outcomes. nTABLE 6-3 is an overview of
TBI management.
ManageMent oF MiLd brain injUry
(gCs sCore 13–15)
Mild traumatic brain injury is defined by a post- resuscitation GCS score between 13 and 15. Often
these patients have sustained a concussion, which is a transient loss of neurologic function following a head injury. A patient with mild brain injury who is conscious and talking may relate a history of disorientation, amnesia, or transient loss of consciousness. The history of a brief loss of consciousness can be difficult to confirm, and the clinical picture often is confounded by alcohol or other intoxicants. Never ascribe alterations in mental status to confounding factors until brain
injury can be definitively excluded. Management
of patients with mild brain injury is described in
(nFIGURE 6-8). (Also see Management of Mild Brain Injury
algorithm on MyATLS mobile app.)
table 6-3 management overview of traumatic brain injury
All patients: Perform ABCDEs with special attention to hypoxia and hypotension.
GCS CLASSIFCATION 13–15 MILD TRAUMATIC BRAIN INJURY 9–12 MODERATE TRAUMATIC BRAIN INJURY 3–8 SEVERE TRAUMATIC BRAIN INJURY Initial Managementa
AMPLE history and neurological exam: ask particularly about use of anticoagulants
Neurosurgery evaluation or transfer required Urgent neurosurgery consultation or transfer required May discharge if admis-
sion criteria not met
Admit for indications below:
*Primary survey and resuscitation *Arrange for transfer to definitive neurosurgical evaluation and management *Focused neurological exam *Secondary survey and AMPLE history
*Primary survey and resuscitation *Intubation and ventilation for airway protection
*Treat hypotension, hy- povolemia, and hypoxia *Focused neurological exam
*Secondary survey and AMPLE history Determine mech- anism, time of injury, initial GCS, confusion, amnestic interval, seizure, headache severity, etc. *Secondary survey including focused neurological exam No CT available, CT abnormal, skull fracture, CSF leak Focal neurological deficit GCS does not return to 15 within 2 hours Diagnostic *CT scanning as determined by head CT rules (Table 6-3) *Blood/Urine EtOH and toxicology screens CT not available, CT abnormal, skull fracture Significant intoxication (admit or observe)
*CT scan in all cases *Evaluate carefully for other injuries *Type and crossmatch, coagulation studies
*CT scan in all cases *Evaluate carefully for other injuries
*Type and crossmatch, coagulation studies aItems marked with an asterisk (*) denote action required.
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table 6-3 management overview of traumatic brain injury (continued) All patients: Perform ABCDEs with special attention to hypoxia and hypotension.
GCS CLASSIFCATION 13–15 MILD TRAUMATIC BRAIN INJURY 9–12 MODERATE TRAUMATIC BRAIN INJURY 3–8 SEVERE TRAUMATIC BRAIN INJURY Secondary Management *Serial exam- inations until GCS is 15 and patient has no perseveration or memory deficit *Rule out indication for CT (Table 6-4) *Perform serial examinations *Perform follow-up CT scan if first is abnormal or GCS remains less than 15 *Repeat CT (or transfer) if neurological status deteriorates *Serial exams *Consider follow-up CT in 12–18 hours
*Frequent serial neurological exam-inations with GCS *PaCO2 35-40 mm Hg
*Mannitol, brief hyperventi- lation, no less than 25 mm Hg for deterioration
*PaCO2 no less than 25 mm
Hg, except with signs of cerebral herniation. Avoid hyperventilation in the first 24 hours after injury when cerebral blood flow can be critically reduced. When hyperventilation is used SjO2 (jugular venous oxygen saturations ) or PbTO2 (brain tissue O2 partial pressure), measurements are recommended to monitor oxygen delivery.
*Address intracranial lesions appropriately
Disposition *Home if patient does not meet criteria for admission *Discharge with Head Injury Warning Sheet and follow-up arranged Obtain neuro- surgical evaluation if CT or neurological exam is abnormal or patient status deteriorates *Arrange for medical follow-up and neuropsychological evaluation as required (may be done as outpatient) *Repeat CT immediately for deterioration and manage as in severe brain injury *Transfer to trauma center
*Transfer as soon as possible to definitive neurosurgical care
aItems marked with an asterisk (*) denote action required.
114 CHAPTER 6 n Head Trauma
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nFIGURE 6-8 Algorithm for Management of Mild Brain Injury. (Adapted with permission from Valadka AB, Narayan RK, Emergency room
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Most patients with mild brain injury make unevent- ful recoveries. Approximately 3% unexpectedly deteriorate, potentially resulting in severe neurological dysfunction unless the decline in mental status is detected early.
The secondary survey is particularly important in evaluating patients with mild TBI. Note the mechanism of injury and give particular attention to any loss of consciousness, including the length of time the patient was unresponsive, any seizure activity, and the subsequent level of alertness. Determine the duration of amnesia for events both before (retro- grade) and after (antegrade) the traumatic incident. Serial examination and documentation of the GCS score is important in all patients. CT scanning is the preferred method of imaging, although obtaining CT scans should not delay transfer of the patient who requires it.
Obtain a CT scan in all patients with suspected brain injury who have a clinically suspected open skull fracture, any sign of basilar skull fracture, and more than two episodes of vomiting. Also obtain a CT scan in patients who are older than 65 years (nTABLE 6-4).
CT should also be considered if the patient had a loss of consciousness for longer than 5 minutes, retrograde amnesia for longer than 30 minutes, a dangerous mechanism of injury, severe headaches, seizures, short term memory deficit, alcohol or drug intoxication, coagulopathy or a focal neurological deficit attributable to the brain.
When these parameters are applied to patients with a GCS score of 13, approximately 25% will have a CT finding indicative of trauma, and 1.3% will require neurosurgical intervention. For patients with a GCS score of 15, 10% will have CT findings
indicative of trauma, and 0.5% will require neuro- surgical intervention.
If abnormalities are observed on the CT scan, or if the patient remains symptomatic or continues to have neurological abnormalities, admit the patient to the hospital and consult a neurosurgeon (or transfer to a trauma center).
If patients are asymptomatic, fully awake and alert, and have no neurological abnormalities, they may be observed for several hours, reexamined, and, if still normal, safely discharged. Ideally, the patient is discharged to the care of a companion who can observe the patient continually over the subsequent 24 hours. Provide an instruction sheet that directs both the patient and the companion to continue close observation and to return to the ED if the patient develops headaches or experiences a decline in men- tal status or focal neurological deficits. In all cases, supply written discharge instructions and carefully review them with the patient and/or companion
(nFIGURE 6-9). If the patient is not alert or oriented
enough to clearly understand the written and verbal instructions, reconsider discharging him or her.
Source: Adapted from Stiell IG, Wells GA, Vandemheen K, et al. The
Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357:1294.
*Patients on anticoagulation were excluded from the use of Canadian CT Head Rule.
table 6-4 indications for ct scanning in patients with mild tbi
Head CT is required for patients with suspected mild brain trauma (i.e., witnessed loss of consciousness, defi- nite amnesia, or witnessed disorientation in a patient with a GCS score of 13–15) and any one of the following factors:
High risk for neurosurgical intervention:
• GCS score less than 15 at 2 hours after injury • Suspected open
or depressed skull fracture
• Any sign of basilar skull fracture (e.g., hemotympanum, raccoon eyes, CSF otorrhea or rhinorrhea, Battle’s sign)
• Vomiting (more than two episodes)
• Age more than 65 years • Anticoagulant use*
Moderate risk for brain injury on CT:
• Loss of consciousness (more than 5 minutes) • Amnesia before impact
(more than 30 minutes) • Dangerous mechanism (e.g., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height more than 3 feet or five stairs)
EVIDENCE-BASED TREATMENT GUIDELINES 115
pitfAll
pReveNtioN
Patient suffers second TBI soon after treatment for initial mild brain injury.
• Even when a patient appears neurologically normal, caution him or her to avoid activities that potentially can lead to a secondary brain injury (e.g., vigorous exercise, contact sports, and other activities that reproduce or cause symptoms).
• Reassessment at outpatient follow up will determine timing of return to full activity or the need for referral for rehabilitative/cognitive services.
116 CHAPTER 6 n Head Trauma
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