Traumatic brain injury Management

Traumatic brain injury is common and a major cause of morbidity and mortality worldwide. Management is based on avoidance of secondary injury, maintenance of cerebral perfusion pressure, and optimization of cerebral oxygenation. Multimodality monitoring of the injured brain enables individualized therapeutic targets to be set to optimize patient management. Patients with moderate or severe brain injury should be managed in a specialist neurosurgical center.

Traumatic brain injury (TBI)

                   Traumatic brain injury (TBI) is the leading cause of death and disability in young adults in the developed world. It can be divided into primary and secondary brain injury. The primary injury occurs as a consequence of the initial physical insult. The pattern and extent of damage will depend on the nature, intensity, and duration of the impact. Compression and shearing forces may result in skull fracture, contusions, intracranial haematoma, cerebral oedema, and diffuse brain injury.

Neurological injury progresses over hours and days, resulting in a secondary injury.Inflammatory and neurotoxic processes result in vasogenic fluid accumulation within the brain, contributing to raised intracranial pressure (ICP), hypoperfusion, and cerebral ischaemia. Secondary injury also occurs as a result of further physiological insults. Hypoxia, hypotension, hyper- or hypocapnia, hyper- or hypoglycaemia have all been shown to increase the risk of secondary brain injury.

Acute management

This is a crucial period when mortality and morbidity can be influenced by interventions to prevent secondary brain injury.

Pre-hospital care

This includes simultaneous assessment, stabilization, and therapeutic interventions. The priorities are to prevent hypoxia and hypotension, both common findings after trauma. Despite widespread agreement on the principles of early management there is less clarity on resuscitation endpoints, with expert panels offering differing guidelines for management. While the Brain Trauma Foundation (BTF) suggests targeting formula to avoid hypoxia.

Imaging

The investigation of choice is CT scanning. Early imaging reduces time to detection of life-threatening complications and is associated with better outcomes. MRI studies are rarely used in the acutely ill, as they are logistically more complex and take longer. MRI is useful if a penetrating injury with a wooden object is suspected. Skull X-rays are useful only as part of a skeletal survey in children with non-accidental injury.

Transfer

National guidelines on the transfer of patients with TBI are available. Initial resuscitation and stabilization of the patient should be completed before transfer. Although neurosurgical transfers are time-critical, the risks of delayed transfer must be balanced against that of an unstable patient or ill-prepared transfer team.

TBI is common and a major public health problem. Despite a progressive and significant reduction in mortality no single treatment has been shown to improve outcome. Management continues to be focused on prevention of secondary injuries and maintenance of CPP. National guidelines and management algorithms seem to be associated with better survival but ignore individual patient variability and injury-specific factors.

AVA Brain InjuryProgram works to minimize the effects of cognitive and physical disabilities.