Management of moderate and severe traumatic brain injury

Abstract

Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI‐related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI‐related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.

Benefits of Early Tracheostomy in TBI Patients

“…According to the Brain Trauma Foundation [60], patients with severe TBI present pulmonary aspiration risks or compromised airway function, and initial treatment goals include early airway protection, adequate supplemental oxygen, and circulation support, ensuring that adequate oxygen and blood flow are delivered to the brain [61].…”

Civilian gunshot wounds to the head: a case report, clinical management, and literature review

“…ICH is the primary cause of mortality in patients with head trauma, and is a known contributor to secondary brain injury. 31 However, the need for ICP monitoring is not as well de ned in the postoperative management of patients with civilian GWH in the management and prognosis of penetrating brain injury. 3,32,33 Commonly used methods for ICP correction are the infusion of hypertonic saline and mannitol, short-term hyperventilation, CSF drainage, barbiturates and paralytics, and nally decompressive craniectomy.…”

“…However, preventative hyperventilation (PaCO 2 < 35 mmHg) within the rst 24 h has been shown to carry a risk of worsening cerebral perfusion by decreasing cerebral perfusion pressure. 31 Short-term hyperventilation is permitted in the case of abrupt worsening of neurological status or for persistently raised ICP despite the use of sedatives, muscle relaxants, hyperosmolar solutions, or CSF drainage. 34,35 In our case, hyperventilation was a temporary measure for reducing increased ICP.…”

Civilian Gunshot Wounds to The Head: A Case Report, Clinical Management, and Literature Review.

“…And ICH is the primary cause of mortality in patients with head trauma, and is a known contributor to secondary brain injury. 31 However,…”

“…However, preventative hyperventilation (PaCO2<35 mm Hg) within rst 24 hours has been shown to carry a risk of worsening cerebral perfusion by decreasing cerebral perfusion pressure. 31 Short-term hyperventilation is permitted in the case of abrupt worsening of the neurological status or for persistently raised ICP despite the use of sedatives, muscle relaxants, hyperosmolar solutions and CSF drainage. 34,35 In our case, hyperventilation is a temporary measure for reducing increased intracranial pressure.…”