Traumatic Brain Injury

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

The South East 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
Clarify potential coagulopathy/thrombocytopenia 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 be reassessed within an hour of the first assessment 

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 rise intracranial pressure. Treat with:

1. Reassurance
2. Splintage of limb fractures
3. Urinary catheterisation of a full bladder
4. 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 refer to the Head Injury Proforma)

Imaging

When CT is unavailable - transfer all patients with a GCS<15 immediately to a centre with CT capability. Patients with a GCS 15 can be admitted overnight for observation with clear arrangements for urgent transfer if there is deterioration.

Perform a CT within 1 hour of any of the following risk factors being identified:

• GCS<13 on initial assessment in the ED
• GCS<15 at 2 hours after the injury on assessment in the ED
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
•   Post-traumatic seizure (CT immediately if delayed)
• Focal neurological deficit
• >1 episode of vomiting 

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

1. Age ≥ 65 years old
2. Any history of bleeding or clotting disorders
3. Dangerous mechanism of injury:
a. Pedestrian or cyclist struck by a motor vehicle
b. Occupant ejected from a motor vehicle
c. Fall from a height >1m or >5stairs
4. >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

Discuss all of the following with a neurosurgeon:

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

• Introductions: Staff should introduce themselves to family and carers and explain what they are doing.
• ED information sheets: All EDs 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

Transfer 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 with likely progression and deterioration. 

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

Indication for admission:

• New clinically significant abnormality on CT
• GCS<15
• Indication for CT scanning but CT scan unavailable or patient not cooperative
• 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 (defined by local agreement) (regional TBI admission policy)

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 Dr 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 Dr 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 of 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 discharged from the ED with persisting problems following a head injury should initially refer to head injury symptoms website.  Ongoing concern can be referred by their GP for a neurology opinion

Early care and prevention of secondary brain injury

• Head elevation 30 degrees.
• Tape ETT.
• Hb > 90
• Correct coagulopathy (APTTr/PTr <1.5, Platelets > 100)
• Use 0.9% Saline or Plasmalyte 148 if crystalloid is required
• Normoventilation with PaCo2 4.5-5 KPa and PaO2 > 13.
• Only use prophylactic hyperventilation as a temporising
• Measure in the setting of suspected herniation
• Administer antibiotics if penetrating injury, open skull fracture or pre-operative.
• Maintain glycaemic control, avoiding hypoglycaemia
• Avoid steroids
• Maintain MAP > 80mmHg
• Avoid SBP ≤ 90mmHg at all times.
• Maintain normothermia. 

Maintenance of anaesthesia during transfer

• Propofol is preferred for sedation
• Atracurium is preferred for paralysis
• 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 

ICP options

• Parenchymal ICP monitor
• External ventricular drain
• Licox 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 st Line: 250ml bolus of 3% hypertonic saline over 10-15mins (ideally via a central line)
2 nd Line: 1g/kg Mannitol (5ml/kg of 20% Mannitol) bolus replace urine output with crystalloid. Avoid Mannitol in hypotensive or underresuscitated 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 prevention
• Enteral nutrition should be achieved by at least day 5 and at most day 7.
• Commence VTE prophylaxis early (48-72hrs) if the brain injury is stable and the benefit outweighs the risk
• Licox monitoring should ideally be placed aiming for a Pb)2 >20mmHg
• Early tracheostomy is recommended when overall benefit is felt to outweigh complications. 
• Commence antibiotics and vaccinations where appropriate if: penetrating injury, open fracture or pre-surgery
• CSF leaks do not require antibiotics but will require pneumococcal vaccine. 

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
• Surgery is performed within one hour of arrival 

Consideration should be given to emergency evacuation of intracranial haemorrhages 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.