Help for brain injury

Assistance in case of traumatic brain injury consists of taking the following measures:

• Tracheal intubation through the mouth under direct visual control, with manual linear immobilization of the cervical spine (TBI is often combined with injuries to the cervical spine).
• Intravenous induction with a drug that prevents an increase in intracranial pressure due to laryngoscopy. The choice of drug is not important, the main thing is to select a dose that allows avoiding fluctuations in blood pressure (ketamine cannot be used, as it increases blood pressure, cerebral blood flow and ICP). Propofol is widely used.
• Rapid sequence induction with suxamethonium (1 mg/kg) - be aware of the possibility of a full stomach and acute gastric dilation.
• Insert an orograstrapesis tube to decompress the stomach.
• Mechanical ventilation maintaining PaO2>13.5 kPa (100 mmHg) and PaCO24.5-5.0 kPa (34-38 mmHg).
• Maintain sedation and neuromuscular blockade with short-acting drugs (such as propofol, fentanyl, atracurium) to provide ventilation and prevent coughing.
• Fluid therapy with 0.9% saline or colloid to maintain SBP > 90 mmHg - if ICP is monitored, target for MTD > 60 mmHg. Choice of fluid volume is more important than composition, but glucose-containing and hypotonic solutions should be avoided.
• Inotropes may also be required to maintain blood pressure at an adequate level, in particular to mitigate the hypotensive effect of sedatives.
• Mannitol 20% (0.5 g/kg) can be used in the complex treatment of high blood pressure - consultation with specialists from a neurosurgical center is useful.
• Urgent CT in patients with high risk of intracranial hematoma or with GCS < 8 after resuscitation.

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Indications for referral to a neurosurgeon

CT scan shows evidence of fresh intracranial hemorrhage/hematoma. The patient meets the indications for CT, but it cannot be performed on site. The patient's clinical picture is worrisome despite the CT scan.

What will a neurosurgeon want to know when you contact him?

Patient's age and medical history (if any). Medical history and nature of injury. Neurological status. Did the patient speak after injury? GCS at the scene and on arrival at the emergency department. GCS dynamics since admission. Pupillary and limb responses. Cardiorespiratory status: BP and HR, blood gases, chest X-ray. Injuries: skull fractures, extracranial injuries. CT and X-ray data: exclude pneumothorax, other studies dictated by the situation.

Management: Intubated and on mechanical ventilation? Circulatory support? Management of associated injuries, monitoring, medications and fluids administered - doses and timing.

Further medical care for traumatic brain injury

• Conduct a detailed re-examination to identify other damage.
• First of all, it is necessary to treat active bleeding and other life-threatening injuries to the chest and abdominal cavity, while not forgetting about increased intracranial pressure and not stopping its targeted treatment.
• Treat seizures with anticonvulsants - phenytoin 15 mg/kg.
• Discuss indications for CT in TBI with neurosurgeons

Indications for emergency CT

• GCS 12 or lower after resuscitation (e.g., opens eyes only in response to pain or does not respond to spoken language).
• Deterioration in the level of consciousness (decrease in GCS by 2 points or more) or progression of focal neurological symptoms.

Indications for urgent CT

• Confusion or somnolence (GCS 13 or 14) without improvement within the last 4 hours.
• Radiographic or clinical evidence of skull fracture, regardless of level of consciousness.
• The appearance of new neurological symptoms, without worsening.
• GCS 15 without skull fractures, but with one of the following signs:
  • severe, persistent headache;
  • nausea and vomiting;
  • irritability or altered behavior; occasional seizures.

When providing first aid for traumatic brain injury, it is necessary to clearly differentiate this injury from the following conditions:

• Alcohol or drug intoxication.
• Subarachnoid hemorrhage or other spontaneous intracranial hemorrhage.
• Anoxic/hypoxic intracranial injury.

Transportation when providing assistance for traumatic brain injury

• Adequate stabilization and management of traumatic brain injury must be achieved prior to transport.
• All necessary resuscitation and monitoring equipment, medications, intravenous access, and infusion devices must be available during transport.
• Medical personnel performing the transport must have appropriate training and experience in resuscitation and intensive care, and be sufficient in number.
• Good communication and understanding between the sending and receiving institutions is essential before and during transport.
• Records, protocols of examinations and procedures, X-rays and scans must be with the patient.