Clinical Pathway: Evaluation Of Severe Traumatic Brain Injury

Severe Traumatic Brain Injury Key Points

Key Points:
1. Rapid identification of severe traumatic brain injury in the field should prompt rapid transport to a Level I trauma center if possible.

2. Assume concomitant cervical spine injury and use full spinal precautions throughout assesment and treatment.

3. Identify and treat other traumatic injuries simultaneously.

4. Avoid hypotension and hypoxemia.

5. Endotracheal intubation by EMS should only be performed when adequate airway or oxygenation is not otherwise possible.

6. Avoid prophylactic or inadvertent hyperventilation.

7. Resuscitation of shock should follow ATLS protocols, using saline and blood products when necessary.

8. Non-contrast CT scanning offers the most rapid delineation of brain injury.

9. Intracranial pressure monitoring should be obtained early, and appropriate cerebral perfusion pressures should be maintained.

10. Sedation with opiates, benzodiazepines, and low dose propofol should be used when intra¬cranial hypertension is present; care must be taken to treat resulting systemic hypotension.

Severe Traumatic Brain Injury Case Study

Case Study:
You have just started your shift and the charge nurse informs you that EMS has arrived with a 48-year-old man who was involved in a high-speed motorcycle collision. He was not wearing a helmet. He was initially awake and combative on-scene but became lethargic and unresponsive en route to the hospital. He was intubated by EMS prior to arrival. His pupils are unequal; the left is dilated and unreactive. His blood pressure is 136/78; heart rate is 88; oxygen saturation is 100%. He does not respond to verbal or painful stimuli. You suspect that the patient has a severe traumatic brain injury and realize that any hope for a meaningful recovery depends on your ability to mobilize resources, manage the intracranial pressure, and maintain the cerebral perfusion pressure.

Before you even have time to finalize your plan, the EMS radio comes alive. The paramedics are bringing a 78-year-old woman with a history of dementia from a nursing home. The report notes that she suffered a minor fall yesterday, was “lethargic” this morning, and the staff could not arouse her from her nap this afternoon. According to the paramedics, she has a hematoma on her forehead and is protecting her airway but responds only to painful stimuli by withdrawing. Her vital signs are “stable.” EMS is requesting to use RSI to intubate her prior to transport and you are considering the wisdom of their request.

Case Study Conclusion:
The blown pupil raised concern for uncal herniation and consequently you began to hyperventilate the patient and administered mannitol 0.5 gm / kg. Once the pupil normalized, the hyperventilation was discontinued and mechanical ventilation was initiated with a goal arte¬rial PaCO2 of 35 mm Hg. A continuous IV infusion of propofol was started for sedation and prevention of ICP elevation. The on-call neurosurgeon was contacted while the patient was quickly transported to radiology for a non-contrast CT scan of the head, which revealed a large left epidural hematoma. The patient was taken to the operating room for surgical evacuation and decompres¬sive craniotomy. He was subsequently transferred to the intensive care unit for recovery and close monitoring for vasospasm, edema, and secondary injury.

After a brief examination of the second patient, you noticed equal sized pupils with normal reactions to light. You found a right-sided hemiparesis and a positive Babinski’s reflex on the right toe. You identified the GCS as 7 and recommended orotracheal intubation. Using full spinal precautions and inline stabilization, you preoxy¬genated with 100% supplemental oxygen. An IV bolus of lidocaine and a defasciculating dose of vecuronium was given followed by successful rapid sequence intubation with etomidate and succinylcholine. A noncontrast head CT revealed a hyperdense subdural hemorrhage with mid¬line shift. After drainage of the venous hemorrhage, the patient was extubated and discharged back to the nursing home after 14 days without neurologic sequelae.

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