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Traumatic brain injury: initial resuscitation and transfer
NEUROSURGICAL ANAESTHESIA
Traumatic brain injury: initial resuscitation and transfer
Learning Objectives After reading this article you should understand the: C
C
Michael Puntis
C
initial resuscitation of patients with moderate and severe traumatic brain injury general principles of secondary brain injury prevention principles of safe inter-hospital transfer
Toby Thomas
Abstract
A number of prehospital interventions can potentially reduce secondary brain injury. Intubation and ventilation may be performed to control hypoxia, hypercapnia or hypocapnia, or to facilitate the transfer of agitated and combative casualties. Haemorrhage control and the administration of fluids (including blood products) can improve cerebral oxygen delivery and hypertonic saline can be used to control intracranial pressure (ICP). TBI can be difficult to manage and can even be difficult to identify in the prehospital environment. Shock from nonneurological injuries can impair cerebral oxygen delivery and mimic TBI. An isolated head injury can also produce a period of apnoea without significant structural damage (impact brain apnoea).
Traumatic brain injury (TBI) is common and is associated with significant morbidity and mortality. The initial resuscitation and management of patients with TBI is focused on limiting secondary brain injury and this may be complex in patients with significant injuries to other organ systems. The transport of critically ill brain-injured patients for definitive treatment also carries significant risks which must be managed. This review describes the initial resuscitation and transfer of head-injured patients.
Keywords Airway management; cervical spine injury; major trauma; transfer; traumatic brain injury Royal College of Anaesthetists CPD Matrix: 2A11, 2A02, 2F01, 2F03, 3F00
Airway and cervical spine When the patient arrives in the emergency department (ED) an immediate assessment needs to be made to ensure that the airway is patent. This may include confirming the position of an existing airway device, or performing de-novo airway interventions. It may also be necessary to intubate the trachea to prevent aspiration if the airway reflexes are absent, even if the airway is patent. While intubation may be an emergency in the context of airway obstruction, in other situations there is usually time to perform a focussed examination to determine the Glasgow Coma Scale (GCS) score, pupillary size and reactivity and the presence of signs of spinal cord injury. Following induction of anaesthesia further clinical assessment will be limited. If the decision is made to intubate the trachea, it is important to avoid hypotension, hypoxia or a significant increase in ICP. Consideration of the patient’s physiological status is usually more important than individual drug choices. However, in most situations, ketamine and rocuronium are appropriate for induction of anaesthesia in TBI and can be used safely for both rapid sequence intubation and delayed sequence intubation. A fluid bolus may be required to maintain the systemic blood pressure during the transition to positive pressure ventilation and preoxygenation and apnoeic insufflation dramatically reduces the incidence of hypoxia.1 The use of pre-intubation checklists is well established for prehospital intubation, and can also be used to reduce the risk of errors in ED intubations. Cervical spine injuries are relatively rare and are often not associated with a spinal cord injury. However, some injuries may be unstable and there is a risk of iatrogenic injury.2 There is some controversy about cervical spine immobilization, but it is important to consider the risk of cord injury particularly during
Introduction Trauma is the most common cause of death of children and adults under the age of 45 and most traumatic deaths are a result of traumatic brain injury (TBI). Half of all patients with severe TBI also have major extracranial injuries and will therefore require a balanced approach to resuscitation. All significant injuries need to be addressed, especially considering that extracranial injuries have the potential to worsen secondary brain injury, and isolated brain injuries can cause cardiovascular and respiratory complications.
Initial resuscitation Prehospital phase The prehospital management of TBI will vary depending on the capabilities of the responders and the available resources; however, the management priorities remain the same. A rapid assessment needs to be performed, usually in parallel with early resuscitation. Life-threatening injuries need to be systematically identified and treated and the patient must then be packaged and transported for definitive management.
Michael Puntis MRCS FRCA FFICM is a Clinical Fellow in Neuroanaesthesia and Neurocritical Care at the National Hospital for Neurology and Neurosurgery, University College London Hospitals, UK. Conflicts of interest: none declared. Toby Thomas FRCA FFICM is a Consultant in Neuroanaesthesia and Neurocritical Care, National Hospital for Neurology and Neurosurgery, University College London Hospitals, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006
NEUROSURGICAL ANAESTHESIA
intubation. Manual inline stabilization (MILS) should be used during laryngoscopy and the use of a gum elastic bougie or video laryngoscope may help to limit the forces transmitted to the cervical spine. Rigid cervical collars can potentially cause adverse effects and should be removed as soon as cervical injury has been excluded.
Vasopressors are associated with worsening metabolic acidosis and should generally be avoided during the initial resuscitation. However, if hypotension persists and is thought to be caused by vasodilation, then judicious use of vasoconstrictors may help maintain adequate cerebral perfusion pressure. Early administration of tranexamic acid reduces the risk of death in bleeding trauma patients.3 The safety and effectiveness of tranexamic acid in the treatment of isolated TBI is currently being investigated.
Ventilation Mechanical ventilation will be required if the patient has been intubated to maintain a patent and protected airway. However, there may be other indications for ventilation. If the patient is spontaneously hyperventilating or hypoventilating then mechanical ventilation should be used to maintain the pCO2 within an appropriate range (4.5e5.0 kPa). Hypercapnia causes raised ICP and hypocapnia causes cerebral vasoconstriction and may impair oxygen delivery. A ventilator should be used to maintain a consistent minute volume rather than hand ventilation which can cause wide variation in pCO2. Mechanical ventilation may be required for the management of hypoxaemia associated with lung injuries such as contusions. Positive end-expiratory pressure (PEEP) may be helpful in maintaining oxygenation and moderate levels (<12 cmH2O) do not significantly increase the ICP.
Neurological assessment Many major trauma casualties will be unable to cooperate with a comprehensive neurological examination, either because they are intubated and sedated, or because they are confused or distracted by pain. It is important to perform an examination before induction of anaesthesia, although only a very brief assessment is required when the airway needs to be managed urgently. During the initial resuscitation the most important parameters are the GCS score, pupillary size and pupillary response. When life-threatening injuries have been excluded, a secondary survey should include a more extensive neurological assessment. Neurological management Cerebral oedema and intracranial haematoma formation can cause an increase in ICP which is associated with increased mortality.4 Even brief, 5-minute, episodes of raised ICP are associated with worse outcomes.5 During resuscitation it is important to avoid causing unnecessary increases in ICP. Cervical collars and endotracheal tube ties should not compress the jugular veins, adequate analgesia and sedation should be administered, and the patient should be positioned with a 30 elevation of the head of the bed (if cardiovascular status and other injuries allow). Patients with a deteriorating GCS score or pupillary changes suggesting critically raised ICP or imminent herniation may benefit from the administration of hyperosmolar fluids to reduce cerebral oedema. The use of mannitol (0.25e1.0 g/kg) is recommended for the acute treatment of elevated ICP but has never been subject to a randomized comparison against placebo. Hypertonic saline is an alternative agent which may have advantages in haemorrhagic shock. Cerebral autoregulation is often impaired in TBI and cerebral blood flow can become pressure dependent. An increase in ICP with a subsequent fall in CPP will cause cerebral ischaemia and should therefore be avoided. If ICP monitoring is available, the CPP can be calculated and the systemic blood pressure can be increased to maintain adequate cerebral perfusion.
Cardiovascular management The combination of TBI and major haemorrhage can present a clinical challenge because of conflicting haemodynamic goals. Systemic injuries with active bleeding benefit from relative hypotension while the haemorrhage is controlled, conversely, isolated brain injuries require an elevated systolic pressure to maintain adequate cerebral perfusion pressure. The risk of bleeding and the risk of cerebral ischaemia therefore need to be balanced. For patients with isolated head injuries the systolic blood pressure can be targeted to maintain an adequate cerebral perfusion pressure (CPP). If there is evidence of other injuries which are actively bleeding, then a lower blood pressure target may be tolerated but the cut-off is debated (Table 1). Hypotension should be managed by administering fluids to restore normovolaemia. For isolated head injuries crystalloid may be appropriate, but polytrauma will require a combination of blood and blood products to avoid dilutional coagulopathy. Significant and ongoing haemorrhage needs to be managed aggressively and should be controlled before proceeding to the definitive treatment of brain injuries.
Cardiovascular and respiratory targets in severe traumatic brain injury (TBI) Ventilation Cardiovascular
PaO2 > 11 kPa PaCO2 4.5e5.0 kPa Systolic blood pressure (SBP) >90 mmHg (TBI and life-threatening haemorrhage)6 SBP >100 mmHg (isolated TBI, age 50e69)7 SBP >110 mmHg (isolated TBI age 15e49 years)7 SBP >110 mmHg (isolated TBI, age >70 years)7
Imaging It is important to rapidly identify all significant injuries and multislice CT scanning has become an important element of trauma resuscitation. CT is the primary investigation for identifying brain injuries and plain skull or c-spine X-rays and MRI have no role during the resuscitation phase of major trauma. All adults with a moderate or severe head injury should have a CT scan of the head and cervical spine performed within 60 minutes. Other indications for urgent scanning include post-traumatic traumatic seizures, focal neurological
Table 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006
NEUROSURGICAL ANAESTHESIA
deficit or more than one episode of vomiting (Box 1). Patients with mild head injury who have not returned to a GCS score of 15 should also have a scan within 2 hours to exclude intracranial pathology. Repeat imaging may be indicated as brain injury develops, and is essential following any clinical deterioration or significant increase in ICP.
Patients with mild or moderate TBI should be discussed with the regional neurosurgical team for further advice. Timing of transfers Although transfer for definitive treatment is often time critical, the initial resuscitation and stabilization of the patient should be completed and monitoring established before leaving the ED to avoid complications during the journey. Even for emergencies the patient must be transferred safely.
Transfer Trauma networks Regional trauma networks were developed to provide an organized system for collaboration between a central major trauma centre (MTC) and a number of smaller trauma units (TUs) which deliver care for less complex cases. A third level of local hospitals provide emergency department services for minor injuries. Specific triage protocols have been introduced to support decisions regarding which patients should be taken directly from the scene to the MTC and consequently all moderate and severe head injuries are usually transferred directly from the scene to a MTC with neurosurgical capabilities. The requirement for secondary transfer is therefore less common but patients with severe TBI are still admitted to trauma unit in certain situations. For example, if the patient has an obstructed airway, has been undertriaged or self-presents at an ED. Patients with moderate or severe TBI who have been admitted to a TU or local hospital will need to be transferred to an MTC for definitive management of their neurological injury, even if immediate surgical intervention is not required. The urgency of that transfer will depend on their injuries.
Practicalities For time-critical transfers it is important to avoid unnecessary, time-consuming interventions. Often, procedures such as the insertion of arterial and central venous catheters can be deferred, especially for short transfers. The immediate priorities are endotracheal intubation, adequate venous access and ensuring that the ICP can be managed and the systemic blood pressure can be maintained. The fundamental physiological aims do not change when the patient leaves the ED and adequate oxygen delivery and CPP must be maintained during the transfer. If other systemic injuries are present, then it may be necessary to carry additional equipment or to take blood products in the ambulance. It is essential to have a plan for managing any deterioration in the patient’s condition. The transfer team must include an appropriately trained doctor and another healthcare professional, competent in airway management and the treatment of trauma. A checklist should be used to ensure adequate monitoring, equipment, drugs and all patient records are included. A reliable means of communication should be available during the transfer and if there are significant changes in the patient’s condition en-route the MTC consultant or neurosurgeon must be informed as this may result in the patient going directly to theatre. A
Referral After performing a primary survey and critical investigations any patient with injuries which cannot be managed locally should be referred to the MTC. The transfer of patients from a TU to an MTC will vary according to injury pattern and local policies, but generally, isolated, severe TBI with an abnormal CT should be transferred immediately to the regional MTC. Patients with extradural or subdural haematoma with midline shift should also be transferred immediately. For any emergency, it is important to confirm if the patient needs to be transferred to the ED or directly to the operating theatre or angiography suite.
REFERENCES 1 Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015; 65: 371e6. 2 Sundheim SM, Cruz M. The evidence for spinal immobilization: an estimate of the magnitude of the treatment benefit. Ann Emerg Med 2006; 48: 8e9. 217-8- author reply. 3 Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23e32. 4 Vik A, Nag T, Fredriksli OA, et al. Relationship of ’dose’ of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 2008; 109: 678e84. 5 Stein DM, Hu PF, Brenner M, et al. Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury. J Trauma 2011; 71: 364e73. 6 Tobin JM, Dutton RP, Pittet J-F, Sharma D. Hypotensive resuscitation in a head-injured multi-trauma patient. J Crit Care 2014; 29: 313. e1e5. 7 Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2016; 1.
Criteria for performing a CT head scan C C
C C C C C
Glasgow Coma Scale (GCS) score < 13 on initial assessment GCS < 15 at 2 hours after injury on assessment in the emergency department Suspected open or depressed skull fracture Any sign of basal skull fracture Post-traumatic seizure Focal neurological deficit More than one episode of vomiting since the head injury
Head injury: assessment and early management, NICE Clinical guideline [CG176] Published date: January 2014 Box 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006
Traumatic brain injury: initial resuscitation and transfer
Learning Objectives After reading this article you should understand the: C
C
Michael Puntis
C
initial resuscitation of patients with moderate and severe traumatic brain injury general principles of secondary brain injury prevention principles of safe inter-hospital transfer
Toby Thomas
Abstract
A number of prehospital interventions can potentially reduce secondary brain injury. Intubation and ventilation may be performed to control hypoxia, hypercapnia or hypocapnia, or to facilitate the transfer of agitated and combative casualties. Haemorrhage control and the administration of fluids (including blood products) can improve cerebral oxygen delivery and hypertonic saline can be used to control intracranial pressure (ICP). TBI can be difficult to manage and can even be difficult to identify in the prehospital environment. Shock from nonneurological injuries can impair cerebral oxygen delivery and mimic TBI. An isolated head injury can also produce a period of apnoea without significant structural damage (impact brain apnoea).
Traumatic brain injury (TBI) is common and is associated with significant morbidity and mortality. The initial resuscitation and management of patients with TBI is focused on limiting secondary brain injury and this may be complex in patients with significant injuries to other organ systems. The transport of critically ill brain-injured patients for definitive treatment also carries significant risks which must be managed. This review describes the initial resuscitation and transfer of head-injured patients.
Keywords Airway management; cervical spine injury; major trauma; transfer; traumatic brain injury Royal College of Anaesthetists CPD Matrix: 2A11, 2A02, 2F01, 2F03, 3F00
Airway and cervical spine When the patient arrives in the emergency department (ED) an immediate assessment needs to be made to ensure that the airway is patent. This may include confirming the position of an existing airway device, or performing de-novo airway interventions. It may also be necessary to intubate the trachea to prevent aspiration if the airway reflexes are absent, even if the airway is patent. While intubation may be an emergency in the context of airway obstruction, in other situations there is usually time to perform a focussed examination to determine the Glasgow Coma Scale (GCS) score, pupillary size and reactivity and the presence of signs of spinal cord injury. Following induction of anaesthesia further clinical assessment will be limited. If the decision is made to intubate the trachea, it is important to avoid hypotension, hypoxia or a significant increase in ICP. Consideration of the patient’s physiological status is usually more important than individual drug choices. However, in most situations, ketamine and rocuronium are appropriate for induction of anaesthesia in TBI and can be used safely for both rapid sequence intubation and delayed sequence intubation. A fluid bolus may be required to maintain the systemic blood pressure during the transition to positive pressure ventilation and preoxygenation and apnoeic insufflation dramatically reduces the incidence of hypoxia.1 The use of pre-intubation checklists is well established for prehospital intubation, and can also be used to reduce the risk of errors in ED intubations. Cervical spine injuries are relatively rare and are often not associated with a spinal cord injury. However, some injuries may be unstable and there is a risk of iatrogenic injury.2 There is some controversy about cervical spine immobilization, but it is important to consider the risk of cord injury particularly during
Introduction Trauma is the most common cause of death of children and adults under the age of 45 and most traumatic deaths are a result of traumatic brain injury (TBI). Half of all patients with severe TBI also have major extracranial injuries and will therefore require a balanced approach to resuscitation. All significant injuries need to be addressed, especially considering that extracranial injuries have the potential to worsen secondary brain injury, and isolated brain injuries can cause cardiovascular and respiratory complications.
Initial resuscitation Prehospital phase The prehospital management of TBI will vary depending on the capabilities of the responders and the available resources; however, the management priorities remain the same. A rapid assessment needs to be performed, usually in parallel with early resuscitation. Life-threatening injuries need to be systematically identified and treated and the patient must then be packaged and transported for definitive management.
Michael Puntis MRCS FRCA FFICM is a Clinical Fellow in Neuroanaesthesia and Neurocritical Care at the National Hospital for Neurology and Neurosurgery, University College London Hospitals, UK. Conflicts of interest: none declared. Toby Thomas FRCA FFICM is a Consultant in Neuroanaesthesia and Neurocritical Care, National Hospital for Neurology and Neurosurgery, University College London Hospitals, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006
NEUROSURGICAL ANAESTHESIA
intubation. Manual inline stabilization (MILS) should be used during laryngoscopy and the use of a gum elastic bougie or video laryngoscope may help to limit the forces transmitted to the cervical spine. Rigid cervical collars can potentially cause adverse effects and should be removed as soon as cervical injury has been excluded.
Vasopressors are associated with worsening metabolic acidosis and should generally be avoided during the initial resuscitation. However, if hypotension persists and is thought to be caused by vasodilation, then judicious use of vasoconstrictors may help maintain adequate cerebral perfusion pressure. Early administration of tranexamic acid reduces the risk of death in bleeding trauma patients.3 The safety and effectiveness of tranexamic acid in the treatment of isolated TBI is currently being investigated.
Ventilation Mechanical ventilation will be required if the patient has been intubated to maintain a patent and protected airway. However, there may be other indications for ventilation. If the patient is spontaneously hyperventilating or hypoventilating then mechanical ventilation should be used to maintain the pCO2 within an appropriate range (4.5e5.0 kPa). Hypercapnia causes raised ICP and hypocapnia causes cerebral vasoconstriction and may impair oxygen delivery. A ventilator should be used to maintain a consistent minute volume rather than hand ventilation which can cause wide variation in pCO2. Mechanical ventilation may be required for the management of hypoxaemia associated with lung injuries such as contusions. Positive end-expiratory pressure (PEEP) may be helpful in maintaining oxygenation and moderate levels (<12 cmH2O) do not significantly increase the ICP.
Neurological assessment Many major trauma casualties will be unable to cooperate with a comprehensive neurological examination, either because they are intubated and sedated, or because they are confused or distracted by pain. It is important to perform an examination before induction of anaesthesia, although only a very brief assessment is required when the airway needs to be managed urgently. During the initial resuscitation the most important parameters are the GCS score, pupillary size and pupillary response. When life-threatening injuries have been excluded, a secondary survey should include a more extensive neurological assessment. Neurological management Cerebral oedema and intracranial haematoma formation can cause an increase in ICP which is associated with increased mortality.4 Even brief, 5-minute, episodes of raised ICP are associated with worse outcomes.5 During resuscitation it is important to avoid causing unnecessary increases in ICP. Cervical collars and endotracheal tube ties should not compress the jugular veins, adequate analgesia and sedation should be administered, and the patient should be positioned with a 30 elevation of the head of the bed (if cardiovascular status and other injuries allow). Patients with a deteriorating GCS score or pupillary changes suggesting critically raised ICP or imminent herniation may benefit from the administration of hyperosmolar fluids to reduce cerebral oedema. The use of mannitol (0.25e1.0 g/kg) is recommended for the acute treatment of elevated ICP but has never been subject to a randomized comparison against placebo. Hypertonic saline is an alternative agent which may have advantages in haemorrhagic shock. Cerebral autoregulation is often impaired in TBI and cerebral blood flow can become pressure dependent. An increase in ICP with a subsequent fall in CPP will cause cerebral ischaemia and should therefore be avoided. If ICP monitoring is available, the CPP can be calculated and the systemic blood pressure can be increased to maintain adequate cerebral perfusion.
Cardiovascular management The combination of TBI and major haemorrhage can present a clinical challenge because of conflicting haemodynamic goals. Systemic injuries with active bleeding benefit from relative hypotension while the haemorrhage is controlled, conversely, isolated brain injuries require an elevated systolic pressure to maintain adequate cerebral perfusion pressure. The risk of bleeding and the risk of cerebral ischaemia therefore need to be balanced. For patients with isolated head injuries the systolic blood pressure can be targeted to maintain an adequate cerebral perfusion pressure (CPP). If there is evidence of other injuries which are actively bleeding, then a lower blood pressure target may be tolerated but the cut-off is debated (Table 1). Hypotension should be managed by administering fluids to restore normovolaemia. For isolated head injuries crystalloid may be appropriate, but polytrauma will require a combination of blood and blood products to avoid dilutional coagulopathy. Significant and ongoing haemorrhage needs to be managed aggressively and should be controlled before proceeding to the definitive treatment of brain injuries.
Cardiovascular and respiratory targets in severe traumatic brain injury (TBI) Ventilation Cardiovascular
PaO2 > 11 kPa PaCO2 4.5e5.0 kPa Systolic blood pressure (SBP) >90 mmHg (TBI and life-threatening haemorrhage)6 SBP >100 mmHg (isolated TBI, age 50e69)7 SBP >110 mmHg (isolated TBI age 15e49 years)7 SBP >110 mmHg (isolated TBI, age >70 years)7
Imaging It is important to rapidly identify all significant injuries and multislice CT scanning has become an important element of trauma resuscitation. CT is the primary investigation for identifying brain injuries and plain skull or c-spine X-rays and MRI have no role during the resuscitation phase of major trauma. All adults with a moderate or severe head injury should have a CT scan of the head and cervical spine performed within 60 minutes. Other indications for urgent scanning include post-traumatic traumatic seizures, focal neurological
Table 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006
NEUROSURGICAL ANAESTHESIA
deficit or more than one episode of vomiting (Box 1). Patients with mild head injury who have not returned to a GCS score of 15 should also have a scan within 2 hours to exclude intracranial pathology. Repeat imaging may be indicated as brain injury develops, and is essential following any clinical deterioration or significant increase in ICP.
Patients with mild or moderate TBI should be discussed with the regional neurosurgical team for further advice. Timing of transfers Although transfer for definitive treatment is often time critical, the initial resuscitation and stabilization of the patient should be completed and monitoring established before leaving the ED to avoid complications during the journey. Even for emergencies the patient must be transferred safely.
Transfer Trauma networks Regional trauma networks were developed to provide an organized system for collaboration between a central major trauma centre (MTC) and a number of smaller trauma units (TUs) which deliver care for less complex cases. A third level of local hospitals provide emergency department services for minor injuries. Specific triage protocols have been introduced to support decisions regarding which patients should be taken directly from the scene to the MTC and consequently all moderate and severe head injuries are usually transferred directly from the scene to a MTC with neurosurgical capabilities. The requirement for secondary transfer is therefore less common but patients with severe TBI are still admitted to trauma unit in certain situations. For example, if the patient has an obstructed airway, has been undertriaged or self-presents at an ED. Patients with moderate or severe TBI who have been admitted to a TU or local hospital will need to be transferred to an MTC for definitive management of their neurological injury, even if immediate surgical intervention is not required. The urgency of that transfer will depend on their injuries.
Practicalities For time-critical transfers it is important to avoid unnecessary, time-consuming interventions. Often, procedures such as the insertion of arterial and central venous catheters can be deferred, especially for short transfers. The immediate priorities are endotracheal intubation, adequate venous access and ensuring that the ICP can be managed and the systemic blood pressure can be maintained. The fundamental physiological aims do not change when the patient leaves the ED and adequate oxygen delivery and CPP must be maintained during the transfer. If other systemic injuries are present, then it may be necessary to carry additional equipment or to take blood products in the ambulance. It is essential to have a plan for managing any deterioration in the patient’s condition. The transfer team must include an appropriately trained doctor and another healthcare professional, competent in airway management and the treatment of trauma. A checklist should be used to ensure adequate monitoring, equipment, drugs and all patient records are included. A reliable means of communication should be available during the transfer and if there are significant changes in the patient’s condition en-route the MTC consultant or neurosurgeon must be informed as this may result in the patient going directly to theatre. A
Referral After performing a primary survey and critical investigations any patient with injuries which cannot be managed locally should be referred to the MTC. The transfer of patients from a TU to an MTC will vary according to injury pattern and local policies, but generally, isolated, severe TBI with an abnormal CT should be transferred immediately to the regional MTC. Patients with extradural or subdural haematoma with midline shift should also be transferred immediately. For any emergency, it is important to confirm if the patient needs to be transferred to the ED or directly to the operating theatre or angiography suite.
REFERENCES 1 Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015; 65: 371e6. 2 Sundheim SM, Cruz M. The evidence for spinal immobilization: an estimate of the magnitude of the treatment benefit. Ann Emerg Med 2006; 48: 8e9. 217-8- author reply. 3 Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23e32. 4 Vik A, Nag T, Fredriksli OA, et al. Relationship of ’dose’ of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 2008; 109: 678e84. 5 Stein DM, Hu PF, Brenner M, et al. Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury. J Trauma 2011; 71: 364e73. 6 Tobin JM, Dutton RP, Pittet J-F, Sharma D. Hypotensive resuscitation in a head-injured multi-trauma patient. J Crit Care 2014; 29: 313. e1e5. 7 Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2016; 1.
Criteria for performing a CT head scan C C
C C C C C
Glasgow Coma Scale (GCS) score < 13 on initial assessment GCS < 15 at 2 hours after injury on assessment in the emergency department Suspected open or depressed skull fracture Any sign of basal skull fracture Post-traumatic seizure Focal neurological deficit More than one episode of vomiting since the head injury
Head injury: assessment and early management, NICE Clinical guideline [CG176] Published date: January 2014 Box 1
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Puntis M, Thomas T, Traumatic brain injury: initial resuscitation and transfer, Anaesthesia and intensive care medicine (2017), http://dx.doi.org/10.1016/j.mpaic.2017.02.006