Early accurate identification of any brain injury and the prevention of further brain injury from the time of any trauma is a major focus of care. Relatively simple measures which can be instigated early may reduce secondary brain injury. Avoidance of hypoxia and hypotension is fundamental. This TEMPO guidance does not replace the NICE head injury guidance (56) but should be used in the context of the multiply injured or moderate to severe head injured patient.
Primary brain injury
Reduced by prevention programmes that modify the environment, behaviour and any injury force delivered to the brain in a particular incident
Secondary brain injury
In the context of severe trauma, secondary brain injury may be reduced by optimisation of basic physiological parameters:
| A |
Airway obstruction • aggressive basic airway management as GCS allows • early intubation, particularly for the agitated high GCS head injury |
| B |
Oxygenation • maintaining SpO2 >95%, PaO2 >13kPa (check arterial blood gas) • aiming Hb >12g/dl Carbon dioxide • in the intubated patient, maintaining a normal end-tidal CO2 and PaCO2 4–5kPa • titrate end-tidal CO2 to the arterial values |
| C | Blood pressure • in confirmed isolated traumatic brain injury, maintain MAP >90 • in multiply injured patient (traumatic brain injury plus non-compressible bleeding), maintain MAP >70. Stop the bleeding |
| D | Normoglycaemia Impaired venous outflow • loose cervical collar appropriately fitted • tube ties not overtight • in confirmed isolated traumatic brain injury, the whole patient tilted head-up 30 degrees • in multiply injured patient (traumatic brain injury plus non-compressible bleeding), patient flat Seizure activity • aggressive management but no place for prophylactic anticonvulsants |
All patients with moderate to severe traumatic brain injury should be managed as if they have a spinal injury until this is excluded radiologically.
Open head injuries
The wound should be covered with saline soaked gauze and pneumococcal vaccine (Pneumovax) given. IV antibiotics are not necessary in the early stages.
Raised intracranial pressure (ICP)
Signs of a raised ICP include
- asymmetric pupils
- bradycardia
- hypertension (NB. in these circumstances hypertension is a symptom of raised intracranial pressure and should be managed by reducing ICP)
- fixed dilated pupils
Adult patients with a head injury and signs of a raised ICP should be given either
- mannitol 1g/kg over 10mins
- hypertonic saline 5%, 100ml bolus
In patients who have been intubated, attention must also be paid to adequate sedation and analgesia, both of which have significant impact on intracranial pressure. Standard infusions of 2% propofol and neat fentanyl (as per transfer guidelines) should be started.
→ Section 11.d
Transfer infusions: Propofol
→ Section 11.d
Transfer infusions: fentanyl
Neurotrauma referral
All patients with brain injuries must be discussed with the Trauma Network Co-ordination Service prior to any transfer. Trauma units do not need to contact neurosurgery to discuss these patients