TRAUMATIC BRAIN INJURY

(TBI)

Dr Errol Williamson
PGY3
INTRODUCTION
Traumatic brain injury (TBI) is any physical insult (a bump, jolt, or
blow) to the brain that results in temporary or permanent impairment of
normal brain function.

Causes of TBI include:

• Falls (especially in older adults and young children)

• Motor vehicle crashes and other transportation-related causes (eg,
bicycle crashes, collisions with pedestrians)
• Assaults
• Sports activities (eg, sports-related concussions)

The primary goal of treatment for patients with suspected traumatic brain injury is to prevent
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secondary brain injury !!!
CLASSIFICATION
PRIMARY VS SECONDARY
Primary injury includes injury upon the initial impact that causes
displacement of the brain due to direct impact, rapid acceleration-
deceleration, or penetration. These include:
• Contusion (bruise on the brain parenchyma)
• Hematoma (subdural, epidural, intraparenchymal, intraventricular,
and subarachnoid)
• Diffuse axonal injury (stress or damage to axons)

Secondary injury consists of the changes that occur after the initial
insult. It can be due to:
• Systemic hypotension
• Hypoxia
• Increase in ICP

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CLASSIFICATION

ATLS 10th Edition Manual page 109 4

GLASGOW COMA SCALE (GCS)

The primary goal of treatment for patients with suspected traumatic brain injury is to prevent
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secondary brain injury !!!
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SKULL FRACTURES
VAULT VS BASILAR

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 SKULL FRACTURES
OTHER

Open vs Closed

With or without CSF leak

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INTRACRANIAL LESIONS

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INTRACRANIAL
LESIONS

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MANAGEMENT
ATLS PROTOCOL

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 RESUSCITATION &
STABILISATION

AIRWAY WITH
C-SPINE BREATHING CIRCULATION
RESTRICTION
• Perform early endotracheal • Adequate oxygenation and • Maintain Blood pressure
intubation in comatose normocapnia should be
maintained. • Blood volume and Cardiac
patients GCS <8
Output should be maintained
• Control Bleeding sites

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 RESUSCITATION &
STABILISATION

DISABILITY EXPOSURE F….(ADJUNCTS)

Neurological Evaluation
• GCS
• Pupillary examination
• GMR
• Lateralizing signs
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• Look for any additional injuries • Urinary catheter
• The goal for temperature • Gastric catheter
management is normothermia. • ECG
• Core body temperature should be • Pulse Oximetry
kept <38°C.
• Capnography
• Avoid hypothermia !!!
• ABG
• Xrays
• eFast Ultrasound
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 PRIMARY SURVEY

RE-EVALUATE & CONSIDER

THE NEED FOR EARLY
TRANSFER !!!!!

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 SECONDARY SURVEY
HEAD TO TOE EVALUATION
HISTORY
(Signs & symptoms)
Allergies
Medications currently used
Past illnesses/Pregnancy
Last meal
Events/Environment related to the injury
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 SECONDARY SURVEY
HEAD TO TOE EVALUATION
PHYSICAL EXAMINATION
• Head
• C-Spine & Neck
• Chest
• Abdomen & Pelvis
• Perineum
• Musculoskeletal System
• Neurological System
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 SECONDARY SURVEY
HEAD TO TOE EVALUATION
ADJUNCTS

Specialised diagnostic tests:

• CT scans of the Head, C-Spine, chest, abdomen & pelvis
• Urography
• Angiography
• Ultrasound
• Bronchoscopy
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SECONDARY SURVEY

CONTINUOUS RE-EVALUATION

IS

IMPORTANT !!!!
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TO IMAGE OR NOT TO IMAGE
……

CT clinical decision rules

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NEW ORLEANS CT RULE

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 MANAGEMENT
GENERAL MEASURES
• The main objective of treating individuals with TBI is to mitigate the
advancement of secondary brain injury, specifically ischemia.

• This involves the reduction of cerebral edema and intracranial pressure

(ICP) while ensuring adequate cerebral perfusion, oxygen delivery, and
energy supply to the brain

• Head of bed elevated at 30 degrees (reverse Trendelenburg)

to improve cerebral venous outflow.

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MEDICAL THERAPY
Intravenous Fluids & Electrolytes
Administer intravenous fluids, blood, and blood products as
required.
Ringer’s lactate solution or normal saline is thus recommended
for resuscitation.
Avoid hypotonic fluids glucose-containing fluids can cause
hyperglycemia, which can harm the injured brain.
Hypovolemia in patients with TBI is harmful !!!

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MEDICAL THERAPY
Intravenous Fluids & Electrolytes
Hyponatremia must be avoided as this may worsen cerebral
oedema.
TBI patients may also develop diabetes insipidus (DI) or the
syndrome of inappropriate antidiuretic hormone (SIADH).
All patients should have frequent monitoring of the serum
sodium and osmolality levels.

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MEDICAL THERAPY
CORRECTION OF ANTICOAGULATION

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MEDICAL THERAPY
MANAGEMENT OF INTRCRANIAL PRESSURE
HYPERVENTILATION
Normocarbia (paCo2 35-45mmHg) is preferred in most patients.
Hypercarbia (PCO2 > 45 mm Hg) will promote vasodilation and increase
intracranial pressure
Hyperventilation acts by reducing PaCO2 and causing cerebral
vasoconstriction.
Aggressive and prolonged hyperventilation can result in cerebral ischemia

RECOMMENDATION: Use hyperventilation only in moderation and f For

as limited a period as possible

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MEDICAL THERAPY
MANAGEMENT OF INTRACRANIAL
PRESSURE
HYPERVENTILATION
RECOMMENDATION:
Use hyperventilation only in moderation and for as limited period as
possible
Prophylactic hyperventilation (pCO2 < 25 mm Hg) is not recommended !!

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MEDICAL THERAPY
MANNITOL
Mannitol is used to reduce elevated ICP.
(1 g/kg) rapidly (over 5 minutes)
Do not give mannitol to patients with hypotension because mannitol does
not lower ICP in patients with hypovolemia and is a potent osmotic
diuretic.

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MEDICAL THERAPY
HYPERTONIC SALINE
Hypertonic saline may be used to lower ICP
It is the preferable agent for patients with hypotension because it does not
act as a diuretic.
However, there is no difference between mannitol and hypertonic saline in
lowering ICP, and neither adequately lowers the ICP in hypovolemic
patients.
3% saline is recommended for patients with ICP; the recommended
effective doses range from 2-5 mL/kg over 10-20 minutes

SUSANTO, M., & RIANTRI, I. (2022). Optimal Dose and Concentration of Hypertonic Saline in Traumatic Brain Injury: A Systematic
Review. Medeniyet Medical Journal, 37(2), 203-211. https://doi.org/10.4274/MMJ.galenos.2022.75725

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MEDICAL THERAPY
BARBITUATES
Barbiturates are effective in reducing ICP refractory to other measures
They should not be used in the presence of hypotension or hypovolemia.
High-dose barbiturate administration is recommended to control elevated
ICP refractory to maximum standard medical and surgical treatment.
Hemodynamic stability is essential before and during barbiturate therapy

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 MEDICAL THERAPY

NIMODIPINE
is a calcium channel blocker medication used to treat subarachnoid
haemorrhage and prevent cerebral vasospasm? It works by blocking the
influx of calcium ions into smooth muscle cells of the blood vessels,
causing them to relax and dilate. This results in improved blood flow to
the brain and helps to prevent vasospasm, which is a narrowing of the
blood vessels in the brain that can lead to stroke.

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 MEDICAL THERAPY

POST TRAUMATIC SEIZURES

• Post-traumatic epilepsy occurs in approximately 5% of patients admitted

to the hospital with closed head injuries and 15% of individuals with
severe head injuries.

• Acute seizures can be controlled with anticonvulsants, but early

anticonvulsant use does not change long-term traumatic seizure outcome.

• It is imperative to control acute seizures as soon as possible, because

prolonged seizures (30 to 60 minutes) can cause secondary brain injury.

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MEDICAL THERAPY
ANTICONVULSANTS
Anticonvulsants can inhibit brain recovery, so they should be used only
when necessary.
Prophylactic use of phenytoin (Dilantin) or valproate (Depakote) is not
recommended for preventing late posttraumatic seizures (PTS).

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 ACS TQIP
BEST PRACTICES IN
THE MANAGEMENT
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BRAIN INJURY
 SURGICAL
MANAGEMENT
SCALP WOUNDS

• Clean and inspect the wound thoroughly before suturing.

• Carefully inspect the wound, using direct vision, for signs of a skull fracture or
foreign material.

• Blood loss from scalp wounds may be extensive, especially in children and older
adults

• Control scalp haemorrhage by applying direct pressure and cauterising or

ligating large vessels. Then apply appropriate sutures,
• clips, or staples.

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 SURGICAL
MANAGEMENT
DEPRESSED SKULL FRACTURES

• A CT scan is valuable in identifying the degree of depression and, importantly,

excluding the presence of an intracranial hematoma or contusion.

• Depressed skull fractures require operative elevation when the degree of

depression is greater than the thickness of the adjacent skull or when they are
open and grossly contaminated.

• Less severe depressed fractures can often be managed with closure of the
overlying scalp laceration, if present.

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 SURGICAL
MANAGEMENT
INTRACRANIAL MASS LESIONS

A neurosurgeon should manage intracranial mass lesions.

If a neurosurgeon is not available in the facility that initially receives a patient

with an intracranial mass lesion, early transfer to a hospital
with neurosurgical capabilities is essential!!

In exceptional circumstances, a rapidly expanding

intracranial hematoma can be imminently life-threatening
and may not allow time for a transfer.

Emergency craniotomy in a rapidly deteriorating patient by a non-

neurosurgeon should be considered only in extreme
circumstances.

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SURGICAL
MANAGEMENT
PENETRATING BRAIN INJURIES

• CT scanning of the head is strongly recommended to evaluate patients with

penetrating brain injury.

• Objects that penetrate the intracranial compartment or infratemporal fossa

and remain partially exteriorised (e.g., arrows, knives, screwdrivers) must be
left in place until the possible vascular injury has been evaluated and
definitive neurosurgical management established.

• Prophylactic broad-spectrum antibiotics are appropriate for patients with

penetrating brain injury, open skull fracture, and CSF leak.

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 POST-CONCUSSIVE SYNDROME

This describes the constellation of symptoms that commonly occur after mild
traumatic brain injury (TBI), and patients who suffer more than one brain injury
are at increased risk. PCS is a constellation of physical, cognitive, behavioral, and
emotional symptoms occurring after TBI

SECOND IMPACT SYNDROME

Second impact syndrome (SIS), or repetitive head injury syndrome, describes a

condition in which individual experiences a second head injury before
complete recovery from an initial head injury

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 SIGNS & SYMPTOMS

A concussed patient will report any combination of symptoms, including

a headache, nausea, memory loss, dizziness, blurry vision, confusion,
fatigue, photo- or phonophobia, motor or sensory loss, poor hand-eye
coordination, or emotional irritability/labiality.

On physical examination, the patient may have an altered level of

consciousness, retrograde, or post-traumatic amnesia, but generally,
difficulty concentrating and balance seem to be consistently impaired.
Additionally, there may be sensory or motor abnormalities or visual
abnormalities.

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 SUMMARY
• Patients with head and brain injuries must be evaluated efficiently.

• Resuscitate and stabilise all patients via the ATLS protocol

• In a comatose patient, secure and maintain the airway by endotracheal
intubation.
• Perform a neurological examination before paralysing the patient.

• Search for associated injuries.

• The goal of resuscitating a patient with brain injuries is to prevent secondary

brain injury.

• Determine the need for transfer, admission, consultation, or discharge. Contact

a neurosurgeon as early as possible.

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 REFERENCES
• ATLS (Advanced Trauma Life Support) Manual 10th Edition

• ACS TQIP BEST PRACTICES IN THE MANAGEMENT OF TRAUMATIC BRAIN INJURY

2015 guidelines

• Jinadasa, S., & Boone, M. D. (2016). Controversies in the Management of Traumatic Brain Injury.
Anesthesiology clinics, 34(3), 557–575. https://doi.org/10.1016/j.anclin.2016.04.008
• Permenter CM, Fernández-de Thomas RJ, Sherman Al. Postconcussive Syndrome. [Updated 2023
Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK534786/
• May T, Foris LA, Donnally III CJ. Second Impact Syndrome. [Updated 2023 Jul 3]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK448119/

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THE END
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