Table 7.1. Common traumatic brain injury patterns

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Management

Glasgow Coma Scale

• Calculate concurrently with other resuscitation efforts.
  
• Preferably before administration of any sedative or paralytic medications.
  
• Also perform pupillary reflex examination.

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Add the total of each column.

Airway

• Early intubation is indicated in all severe TBI patients.
  
• Maintain c-spine precautions until clearance is possible (i.e., rigid cervical collar, logroll the patient, do not allow them to flex or extend the neck).

Rapid sequence intubation (RSI)

• The cerebral perfusion of severe TBI patients is tenuous, and first pass intubation is critical.
  
• The RSI medications should include a sedative and a paralytic agent with these objectives:
  
  
  
  • Maintenance of hemodynamic stability and CNS perfusion
    
  • Maintenance of adequate oxygenation
    
  • Prevention of increases in intracranial hypertension
    
  • Prevention of vomiting and aspiration.
  
  
• Pretreatment may help minimize increase in intracranial pressure (ICP) during intubation (no strong evidence to support its use and not universally used):
  
  
  
  • Lidocaine (1.5 mg/kg) intravenous push 3 minutes prior to induction
    
  • Fentanyl (3 micrograms/kg) slow intravenous push 3 minutes prior to induction, after lidocaine.

Induction agents

• Etomidate (0.3 mg/kg) has been demonstrated to be hemodynamically stable and not increase ICP.
  
• Ketamine (1.5 mg/kg) should be considered if hypotensive or normotensive (avoid if the patient is already hypertensive).

Paralytic agents

• Rocuronium (RSI dose 1.2 mg/kg), onset of action 45–60 seconds.
  
• Succinylcholine (1.5 mg/kg IV), onset of action 45–60 seconds (avoid in patients with crush injuries).
  
• Vecuronium (0.1–0.2 mg/kg), onset of action 60–90 seconds.

Breathing

• Avoid hypoxemia and hyperoxemia (goal pulse oximeter of 95%).
  
• Monitor with quantitative end-tidal PaCO₂.
  
• Maintain PaCO₂ levels of 35–38 mmHg.

Circulation

• The goal is to maintain blood flow to the brain. The important measure is cerebral perfusion pressure (CPP), as opposed to systolic blood pressure (SBP). CPP = MAP − ICP. Systemic hypotension causes a decrease in CPP and must be avoided. If someone has increased ICP they need a higher blood pressure to maintain cerebral perfusion.
  
• 500 mL to 1 L boluses of isotonic crystalloid should be given to maintain SBP >90.

Intracranial pressure

• Intracranial pressure is normally 15 mmHg.
  
• Traumatic causes of increased ICP:
  
  
  
  • Intracranial mass lesions (hematomas)
    
  • Cerebral edema (acute hypoxic ischemic encephalopathy, large cerebral infarction, severe traumatic brain injury)
    
  • Obstructive hydrocephalus.
  
  
• See the table below for clinical signs of increased ICP and impending herniation.

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