Emergency department management of traumatic brain injuries: A resource tiered review

Abstract

Introduction Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. Objectives Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. Methods A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. Key recommendations Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

Traumatic brain injury and RSI is rocuronium or succinylcholine preferred?

“…For these critically ill patients, it is vital to establish a definitive airway early, as this improves outcomes [10]. Half of patients dying from TBI decompensate within the first 48 h following the initial injury [2], highlighting the importance of early intervention and resuscitation. In a prospective cohort study of patients with TBI in Switzerland, prehospital intubation was associated with improved mortality at 14 days post injury [11].…”

“…These injuries pose a large economic impact with an estimated 2.8 million emergency room visits, hospitalizations, and deaths in 2013 attributable to TBI [1]. There is also significant morbidity and mortality from TBI, with upwards of 27 million cases per year globally [2] and roughly 11.7 deaths per 100,000 persons per year in Europe [3]. In the United States, deaths attributed to TBI account for 2.2% of all deaths [4 ▪▪ ] and at one week after TBI, the overall mortality is estimated to be 33% [5].…”

Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit

“… 8 Despite an estimated 8 million TBI cases per year in Africa, most of which occur in patients who are less than 40 years of age (incidence 801 per 100 000 persons), there is a paucity of African paediatric-specific TBI statistics. 9 …”

ICU management of Traumatic Brain Injury

“…TBI may be primary or secondary. Principles of management of severe TBI (including moderate TBI) in ICU aims at avoidance of secondary injury 4 . Primary causes of secondary brain injury comprise hypotension, hypoxia, hypercarbia, and worsening ICP.…”