Traumatic brain injury

Head injury is the commonest cause of death & disability in people aged between 1 and 40 years in the UK. Twenty percent of admitted patients have evidence of a fracture or brain injury. One in 500 Emergency Department (ED) attendances for head injury result in death. Most deaths occur in the 5% of patients who present to the ED with a GCS (Glasgow Coma Scale) <13.

The North of Scotland Trauma Network utilises the NICE guidelines for head injury. A summary of which follows in this document:

Definitions

Head Injury: Trauma to the head other than superficial injuries to the face.

Focal Neurological deficit – any of the following:

• Difficulties with understanding, speaking, reading, or writing
• Decreased sensation
• Loss of balance
• General weakness
• Visual changes
• Abnormal reflexes
• Problems walking.

High Energy head injury – any of the following:

• Pedestrian vs. car
• Occupant ejected from motor vehicle
• Fall >1m or >5 stairs
• Diving accident
• High-speed Motor vehicle collision (MVC)
• Rollover motor accident
• Accident involving motorised recreational vehicles
• Bicycle collision
• Any other potentially high-energy mechanism.

Base of skull fracture signs – any of the following:

• Clear fluid running from the ears or nose
• Black eye with no associated damage around the eyes
• Bleeding from one or both ears
• Bruising behind one or both ears.

Open or depressed skull fracture or penetrating head injury signs:

• Penetrating injury signs,
• Visible trauma to the scalp or skull of concern to the professional.

Assessments in the ED

Prioritise <C>ABC

Explore possible coagulopathy/thrombocytopenia/anticoagulants early.

Assess GCS:

• Do not ascribe depressed consciousness to intoxication until a head injury has been excluded.
• Assess all patients GCS<15 immediately for CT
• Assess all GCS 15 patients within 15 minutes of arrival for CT
• Patients with a GCS<9 should have early anaesthetic involvement.

Re-assessment:

Patients who do not initially require a CT scan should have observations taken every 30 minutes.

Re-attenders:

Patients who have previously attended the ED for a head injury and return within 48 hours should be seen / discussed with a senior clinician and strong consideration should be given to performing a CT scan.

Further Management

Pain management – pain can increase intracranial pressure.

Treat with:

• Reassurance
• Splinting of limb fractures
• Urinary catheterisation of a full bladder
• Titrate intravenous opioids

Safeguarding issues – Documents any concerns and follow age-appropriate safeguarding procedures.

Head injury proforma – A standardised head injury proforma and observation chart should be used when assessing and observing patients with a head injury (Please use local paper/electronic head injury proforma document.)

Imaging

Perform a CT within 8 hours of the head injury if there has been some loss of consciousness or amnesia and:

• Age ≥ 65 years old
• Any history of bleeding or clotting disorders
• Dangerous mechanism of injury:
  
  • Pedestrian or cyclist struck by a motor vehicle
  • Occupant ejected from a motor vehicle
  • Fall from a height >1m or >5 stairs
• >30 minutes retrograde amnesia of events immediately before the head injury.

Perform a CT scan within 8 hours of injury for all patients on warfarin, even in the absence of any other symptoms.

Assess all patients with a head injury for the possibility of cervical spine injury. See separate Spinal Injury guideline for further details (To be developed).

Discuss all the following with a neurosurgeon:

• New, surgically significant abnormalities on CT
• Persisting GCS 8 or less after initial resuscitation
• Unexplained confusion which persists for >4 hours
• Deterioration in GCS after admission (especially motor response)
• Progressive focal neurological signs
• A seizure without full recovery
• Definite or suspected penetrating injury
• CSF leak.

• Introductions: Staff should introduce themselves to family and carers and explain what they are doing.
• ED information sheets: All EDs (Emergency Departments) should have information available about head injury management.
• Ensure there is a board/area displaying leaflets or contact details for patient support organisations either locally or nationally.

Indications for transfer

Consider transferring all patients with a GCS 8 or less irrespective of the need for neurosurgery.

Indications for intubation prior to transfer:

• GCS <9
• Loss of protective laryngeal reflexes
• Hypoxaemia (PaO2 <13kPa on oxygen)
• Hypercarbia (PaCO2 >6kPa)
• Spontaneous hyperventilation (PaCO2 <4kPa)
• Irregular respirations
• A deterioration of 1 point or more on the motor score
• Unstable facial fractures
• Copious bleeding into mouth (e.g., from BOS fracture)
• Seizures
• Brain injury.

Preventing Secondary Brain injury:

• PaO2 >13 kPa.
• PaCO2 4.5 -5.0 KPa
  
  • Only temporarily hyperventilate to treat signs of raised intracranial pressure. Increase FiO2 during hyperventilation.
  • MAP ≥ 80mmHg with volume or vasopressor as indicated.

Polytrauma Patient

• All advice sought from and referrals to the MTC and neurosurgery should be made using the Scotstar Emergency number (03333 990 222) which will enable the SPOC Consultant to be brought into a conference call along with any specialty required and the relevant retrieval team. Please see separate Transfer Policy.

Isolated Head Injury

• All Local Emergency Hospitals should use the ScotStar Emergency number (03333 990 222) as above for advice and referral.
• The Trauma Unit should consider using the Trauma Transfer Line but can contact neurosurgery directly for isolated brain injured patients. Neurosurgery should inform the SPOC if the patient is unstable and would need to be received in the Resus room after a transfer is agreed.

Indication for admission:

• New clinically significant abnormality on CT
• GCS<15
• Indication for CT scanning but CT scan unavailable or patient not co-operative
• Continuing worrying signs (e.g., persistent vomiting, Severe headache)
• Other concerns (drug/alcohol intoxication, meningism, CSF leak).

Admitting team

Admit under a team led by a consultant who has been trained in head injury management (not limited to neurosurgery specialists).

Click here for NEWS Chart

Observations

The minimum observations are:

• GCS
• Pupil size and reactivity
• Limb movements
• Respiratory Rate
• Heart Rate
• Blood Pressure
• Temperature
• SpO₂

Frequency of observations if GCS<15 at any time

Every 30 minutes.

Frequency of observations if GCS 15 on presentation in ED

• Every 30 minutes for 2 hours
• Then hourly for 4 hours
• Then every 2 hours.

Escalation Criteria

Call the supervising Doctor if there is any of the following:

• New agitation or abnormal behaviour
• Sustained (30 minutes) drop of 1 point in GCS (especially if motor)
• Any drop of 3 points in E or V score
• Any drop of 2 points in M score
• New severe or increasing headache
• New persisting vomiting
• New neurological symptoms or signs e.g., pupil inequality, asymmetry of facial or limb movement.

Repeat CT

The Doctor should arrange an immediate CT scan if the escalation criteria are confirmed on assessment.

Further Head imaging after 24 hours

Patients who remain GCS <15 after 24 hours observation should be considered for a repeat CT or MRI even if the first CT was normal.

Discharge from the ED

The patient must meet all the following criteria:

• Normal CT or CT not indicated
• GCS 15
• Somebody at home to supervise or nobody at home but suitable supervision arranged, or risk of late complication deemed negligible
• No other indication for admission:
  
  • Drug or alcohol intoxication
  • Other injuries
  • Shock
  • Meningism
  • CSF leak.

Discharge following admission

Patients can be discharged once all significant symptoms have resolved, and they have suitable supervision arrangements.

Discharge advice

Give verbal and printed discharge advice for all patients who are discharged.

Drug and Alcohol liaison

Offer information on alcohol and drug misuse to patients in whom this was an issue.

Follow Up

Patients with persisting problems following a head injury should contact the TC/TU Trauma Coordinator for further referral. Contact details here.

• Head elevation 30 degrees.
• Tape ETT.
• Hb > 90
• Correct coagulopathy (APTTr/PT <1.5, Platelets > 100)
• Use 0.9% Saline or Plasmalyte 148 if crystalloid is required.
• Normoventilation with PaCO₂ 4.5-5 kPa and Pa O₂ > 13kPa.
• Only use prophylactic hyperventilation as a temporising measure in the setting of suspected herniation
• Administer antibiotics if penetrating injury, open skull fracture or pre-surgery.
• Maintain glycaemic control, avoiding hypoglycaemia
• Avoid Steroids
• Maintain MAP > 80mmHg
• Always avoid SBP ≤ 90mmHg.
• Maintain normothermia.

Maintenance of Anaesthesia During Transfer

• Propofol is preferred for sedation
• Intermittent or continuous narcotics can be utilised
• Monitor pupil size and reactivity every 30 minutes.

Indications for ICP Monitor

All patients deemed salvageable with a GCS<9 and either:

• Abnormal CT and:
  • Haematoma
  • Contusion
  • Swelling
  • Herniation
  • Compressed basal cisterns or
• Normal CT with any 2 of the following:
  
  • Age>40
  • Unilateral or bilateral posturing
  • SBP<90mmHg.

Please also refer to the Brain Trauma Foundation’s guidelines on the Management of Severe Traumatic Brain Injury (Click here)

ICP Options

• Parenchymal ICP monitor
• External Ventricular drain
• Raumedic ICP / PbO₂ monitor.

ICP Targets

• ICP ≤20mmHg
• A combination of ICP values and CT findings may be used to make management decisions on ICP treatment thresholds.

CPP Targets

• CPP 60-70mmHg
• Avoid aggressive attempts to maintain CPP >70mmHg with fluids and pressors unless directed by PbO₂ targets.

Treatment of Intracranial Hypertension

Treatment of known or suspected intracranial hypertension remains a cornerstone in patients with severe brain injury. Patients with intracranial hypertension should receive the following treatments.

Whilst Awaiting ICP Monitor Placement

1. 1st Line: 250ml bolus of 3% Hypertonic Saline over 10-15mins (ideally via a central line).
2. 2nd Line: 1g/kg Mannitol (5ml/kg of 20% Mannitol) bolus.

Replace Urine output with crystalloid. Avoid Mannitol in hypotensive or under-resuscitated patients.

Once ICP Monitor Placed

Please refer to the Treatment of Intracranial Pressure in Adults Document.

Other Measures:

• Avoid and treat hyperthermia
• Elevate head of bed to 30-45 degrees. Use reverse Trendelenburg if spinal injury.
• Gastric Ulcer prophylaxis
• Enteral nutrition should be established within 24 hours and achieved by day 5 and at most day 7. TPN should be considered if this is not thought possible.
• Consider VTE prophylaxis early (48-72hrs) if the brain injury is stable and the benefit outweighs the risk.
• PbO₂ monitoring should ideally be always placed aiming for a target PbO₂ >20mmHg (see appendix 5).
• Tracheostomy should be considered where overall benefit is felt to outweigh complications.
• Commence antibiotics and vaccinations where appropriate if: penetrating injury, open fracture, or pre-surgery.

Quality Standards

• The registrar should discuss all neurosurgical referrals with the consultant and clearly document this.
• All decisions to perform neurosurgery are discussed with a consultant.
• Patient should be in surgery within one hour of arrival.

Consideration should be given to emergency evacuation of intracranial haemorrhage if there is significant local or generalised mass effect and patient is at risk of clinical deterioration and/or death. Small or moderate haematomas can be scheduled urgently on CEPOD if they have normal conscious level but severe headache. They would need to be observed in a critical care environment with 30-minute observations.