Traumatic Brain Injury: Reducing Secondary Brain Injury

Viet Tran

I'm almost breaking the first rule of simulation here by talking about it outside of the arena - but not to miss an educational intervention i thought we should revisit the principles of looking after a TBI rolling through the door.

​29yo male. MVA with clear isolated head trauma. GCS3.

Primary Survey
Secondary Survey with the addition of active management to prevent secondary brain damage

HEADS UP

Kate Field reminded us of the mnemonic HEADS UP to help remember how to reduce secondary brain injury

HYPOXIA/HYPOCARBIA prevention
ENVIRONMENTAL CONTROL
ANTICONVULSANTS/ANTICOAGULANTS
DIABETIC CONTROL
SEDATION

UP
PRESSURE

 Hypoxia/Hypocarbia prevention

• RSI: protect the airway and prevent hypoxemia
• Ventilate to pCO2 35-40 mmHg

Environmental Control

• Aim for normothermia (previously thought hypothermia was beneficial but cochrane thinks otherwise)

Anticonvulsants/Anticoagulants

• Phenytoin (15-20mg/kg) has been extensively studied - check with local guidelines
• Is there a reversible anticoagulant on board and is reversal indicated?

Diabetic Control

• Hypermetabolic response to stress = Hyperglycemia
• Hyperglycemia is a known surrogate to increased mortality
• Aim for BSL 4-9 mmol/L

Sedation

• Agitation leads to increased ICP - keep them sedated AND keep them comfortable

​
Up & ICP control

• Head up 20-30 degrees
• Avoid cervical venous compression (eg cervical collar, tube ties)

Hyperosmotic agents: Mannitol (can use hypertonic saline...but)

• Also scavengers free radicals
• Reduces ICP within 30min
• Bolus dose 1g/kg
• 2ry effect includes intravascular volume loss (diuretic effect)

Pressure

• ​Aim for a MAP of 70-80mmHg
• Too high? Intubate, Increase Analgesia/Sedation, Paralysis
• Too low? Fluids, Noradrenaline

So the simulated patient made it to theatre without need for emergency department decompression...perhaps for another time?