Management of Traumatic Brain Injury: A Simple and Logical Approach

Educational Objectives

The goal of this program is to improve management of traumatic brain injury (TBI). After hearing and assimilating this program, the clinician will be better able to:

1. Cite evidence regarding the outcomes in use of prehospital tranexamic acid in TBI.
2. Use a tiered approach to TBI treatment escalation according to the Western Trauma Association TBI management guidelines.

Summary

Introduction: in traumatic brain injury (TBI), primary treatment for mitigating the initial injury does not improve outcomes; the focus should be on preventing secondary injury

Prehospital intubation (PHI): in one study (Gravesteijn et al [2020]), though PHI was beneficial for extracranial injury, it was better to intubate patients with TBI in the hospital; in patients who are breathing, maintaining oxygen saturation, and with a respiratory drive, PHI has never been shown to improve outcomes; during intubation, hypoxia, hypotension, and hyperventilation may occur that independently worsen the outcome; the benefits and harms of intubation should be carefully evaluated in patients with TBI to optimize benefit

Prehospital mannitol: not beneficial; small benefit present for intracranial pressure (ICP)-directed mannitol at the hospital

Prehospital tranexamic acid (TXA): in the CRASH-3 trial, there was no difference in outcomes between patients with severe TBI with low Glasgow Coma Scale (GCS) who received prehospital TXA (≤3 hr of TBI) vs placebo (CRASH-3 trial collaborators [2019]); however, TXA improved outcomes in patients with mild to moderate TBI, and there were no side effects

ICP management: according to the Brain Trauma Foundation guidelines (Carney et al [2017]), if a patient has severe TBI, low GCS score, and a positive finding on computed tomography (CT), there is a modest recommendation to measure the ICP and to have a goal for cerebral perfusion pressure (CPP; level 2B recommendation); there is no difference in outcomes between using best clinical judgment vs monitoring ICP (Chesnut et al [2012]); managing the brain injury and avoiding further brain damage are important

Hypothermia: Andrews et al (2015) found that in patients with ICP >20 mm Hg after TBI, therapeutic hypothermia (32-35°C) to reduce ICP did not result in better outcomes vs standard care; it was suggested that the results were related to delayed hypothermia treatment (ICP >20 mm Hg may have already induced brain damage); in a prospective randomized trial (Cooper et al [2018]), early prophylactic hypothermia for severe TBI did not lower the ICP or improve outcomes

Decompressive craniectomy (DC): can be performed for space-occupying bleeding in TBI; in patients with diffuse swelling (severe TBI) and high ICP, early and aggressive bifrontal DC decreased ICP but was associated with worse outcomes (Cooper et al [2011]); unilateral and small (limited) craniectomy (depending on clinical judgment of benefit to patients) performed as a rescue treatment after the failure of medical management had better outcomes (Hutchinson et al [2016])

The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) guidelines: keep pulse oximetry values high; ensure good arterial oxygen pressure, systolic blood pressure of ≥100 mm Hg (≥110 mm Hg for younger and elderly patients); prevent hypo-osmolarity, hypoglycemia, hyperglycemia, and temperature spikes in patients; maintain ICP ≤22 mm Hg and a normal temperature

Western Trauma Association TBI management guidelines (Alam et al [2020]): supportive care for all patients with TBI — standard trauma care, hemorrhage control, appropriate resuscitation, elevation of the head of the bed, and addressing other causes of increased ICP (eg, increased intrathoracic pressure, abdominal compartment syndrome [decompressive laparotomy decreases ICP], breath stacking, high tidal volumes); basic prevention strategies — avoid hyperventilation, hyperglycemia, hypoglycemia, and hyponatremia; start feeding patients early and treat infections

Initial management: for patients with suspected severe TBI, perform CT and clinical evaluation; if they have dilated pupil or impending herniation, hyperosmolar therapy can be initiated early; if they have TBI and have indications for primary DC (eg, space-occupying bleeding) perform DC; if they do not, check if they have indications for ICP monitor placement; initiate supportive care for all patients

Tier 1 interventions: if the ICP is not adequately controlled (≤22 mm Hg), consider deeper sedation, strong analgesics, and other measures to reduce ICP (eg, addressing breath stacking); it is important to have a liberal threshold for repeating the CT

Tier 2 interventions: add deeper sedation, administer hyperosmolar therapy and vasopressor agents to maintain CPP ≥60 mm Hg, and maintain the partial pressure of carbon dioxide ≈35 mm Hg

Tier 3 interventions: if tier 2 interventions do not work, consider deeper sedation, barbiturate coma, or propofol

Rescue interventions: if ICP is not adequately controlled with tier 1 to tier 3 interventions, DC for diffuse swelling can be performed; having clear management guidelines, a tiered approach to treatment escalation, and a standardized algorithm is beneficial

Readings

ACS TQIP Best practices in the management of traumatic brain injury. https://www.facs.org/media/mkej5u3b/tbi_guidelines.pdf; Alam HB, Vercruysse G, Martin M, et al. Western Trauma Association critical decisions in trauma: Management of intracranial hypertension in patients with severe traumatic brain injuries. J Trauma Acute Care Surg. 2020;88(2):345-351. doi:10.1097/TA.0000000000002555; Andrews PJ, Sinclair HL, Rodriguez A, et al. Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. N Engl J Med. 2015;373(25):2403-2412. doi:10.1056/NEJMoa1507581; Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6-15. doi:10.1227/NEU.0000000000001432; Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in traumatic brain injury [published correction appears in N Engl J Med. 2013 Dec 19;369(25):2465]. N Engl J Med. 2012;367(26):2471-2481. doi:10.1056/NEJMoa1207363; Cooper DJ, Nichol AD, Bailey M, et al. Effect of early sustained prophylactic hypothermia on neurologic outcomes among patients with severe traumatic brain injury: The POLAR randomized clinical trial. JAMA. 2018;320(21):2211-2220. doi:10.1001/jama.2018.17075; Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury [published correction appears in N Engl J Med. 2011 Nov 24;365(21):2040]. N Engl J Med. 2011;364(16):1493-1502. doi:10.1056/NEJMoa1102077; CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): A randomised, placebo-controlled trial [published correction appears in Lancet. 2019 Nov 9;394(10210):1712]. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0; Gravesteijn BY, Sewalt CA, Nieboer D, et al. Tracheal intubation in traumatic brain injury: a multicentre prospective observational study. Br J Anaesth. 2020;125(4):505-517. doi:10.1016/j.bja.2020.05.067; Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med. 2016;375(12):1119-1130. doi:10.1056/NEJMoa1605215.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Alam was recorded at the 2024 Combined Arizona Chapter of the American College of Surgeons Annual Meeting/Phoenix Surgical Symposium, held February 8-10, 2024, in Scottsdale, AZ, and presented by the Phoenix Surgical Society and Banner Health. For information on upcoming CME activities from this presenter, please visit http://www.phoenixsurgicalsociety.com/conference-information/. Audio Digest thanks the speakers and the presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS711004

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.