Management of Severe Head Injuries
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Traumatic brain injury: an evidence-based review of management

Traumatic brain injury: an evidence-based review of management | Management of Severe Head Injuries | Scoop.it
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head_trauma_2006.pdf

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In the UK head injury is responsible for 1,000,000 hospital cases each year. With severe brain injury occurring in between 10 to 15 per each 100,000 presentations. In Warwick, UK the prehospital management of head trauma includes assessment of the neurological state of the patient after addressing the Airway, breathing and circulation adequately. The airway should be cleared and maintained and an airway adjunct should be inserted if necessary. Manual c-spine immobilization due to potential injury during airway manoeuvres must be maintained. A respiratory rate of between 10 and 30 breaths per minute with visible, equal chest rise and fall. Haemorrhage control and fluid replacement are important in raising and maintaining the blood pressure. Maintenance of circulation is vital to maintain cerebral perfusion. A simple AVPU score and pupillary size is sufficient. A formal GCS can be done but needs to be reliable and reproducible. Administration of high concentration oxygen via a non-rebreathing mask to ensure patient has an oxygen saturation of over 95% excluding chronic obstructive pulmonary disease (COPD).  C-spine should be assumed. Treating hypoxia  and preventing hypercarbia is fundamental. Consideration of assisted ventilation at a rate of 12-20 respirations per minute if oxygen saturation is < 90% on high flow oxygen, resp rate is <10 or >30 or chest expansion is inadequate. A combative patient is unlikely to have inadequte ventilaations but may be hypoxic. Cerebral perfusion pressure (CPP) needs to be maintained for patient benefit. It is determined by mean arterial pressure (MAP) and intracranial pressure (ICP). Fluid resuscitation must not be delay transport. If both radial and carotid pulse are present do not commence fluid resuscitation. Transfer to further care. Main goal is to ensure sufficient oxygenation. 

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Sports%20Related%20Severe%20TBI.pdf

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In a case study conducted by Sloan (2003) it is mentioned that hyperventilation is considered as a treatment for severe traumatic brain injury (TBI). It is recommended that the pCO2 should not be maintained below 25 mm Hg even in severe TBI patients. Early prophylactic hyperventilation with pCO2 levels below 35 mmHg should be avoided. Hyperventilation can be used in the face of acute neurological deterioration or in cases of persistent intracranial hypertension that fails other medical interventions. The option of testing for cerebral ischemia using oxygen saturation monitoring is suggested if it is essential to maintain the patients pCO2 below 30mmHg. There has only been one controlled study regarding the use of hyperventilation in TBI and it is not clear that it improves neurological outcome. More studies need to be carried out before hyperventilation can become intervened into a management plan. Sloan (2003) confirms that the most important management of TBI includes initial rapid physiologic resuscitation if required and the use of sedation and short acting neuromuscular blockade if required. Blood pressure and cerebral perfusion pressure (CPP) need to be maintained. It is recommended that a Systolic Blood Pressure (SBP) of above 90 mmHg, a Mean Arterial Pressure (MAP) of above 90 mmHg  and a CPP of over 70 mmHg is maintained. Fluid infusion may be needed to reach this goal. 

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Head Trauma Treatment & Management

Treatment & Management: Head Trauma. Traumatic brain injury (TBI) continues to be an enormous public health problem, even with modern medicine in the 21st century.
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Crippen (2012) divides the treatment of head injury into closed head injury and penetrating head injury. Closed head injury treatment has been further divided into the treatment of mild, moderate and severe head injuries. Crippen (2012) states the majority of head injuries are mild injuries however 3% of mild head injuries progress to serious injury. Patients with mild head injuries associated with headaches, dizziness and nausea are considered low-risk injuries. Many of these patients require minimal treatment and observation after being assessed carefully. The treatment defined by Crippen (2012) is inclusive of both prehospital and hospital care. Patients with mild head injuries usually present with concussions. Concussions are graded on a scale from I-V with grade I concussion being the least severe and grade V concussion being more severe. In grade V concussion the patient typically has loss consciousness for longer than 10 minutes. It is important to understand concussion and the effects each grade of concussion has on the treatment of the patient. Crippen (2012) states patients that display persistent emesis, anterograde amnesia, severe headaches, loss of consciousness or  signs of alcohol or drug intoxication are considered to have moderate-risk head injury. Crippen (2012) relates the identification of serious complications of moderate head injuries to treatment stating patients that have received a moderate-risk head injury will need a CT scan in hospital. Patients with these more advanced symptoms must be monitored carefully by paramedics in the prehospital field. Paramedics are able to treat patients symptoms regarding emesis by administration of ondansetron as well as pain by paracetamol, methoxyflurane, fentanyl or morphine; oxygen and fluids must also be considered. Crippen (2012) relays the importance of serially assessing the GCS of a patient in any head injury. This way any deterioration can be recognised early. The patient of course, must be haemodynamically stable before a neurological status assessment takes place. The patients pupillary response is vital to check serially for any deterioration or abnormalities in head trauma. Crippen's (2012) insight into the different severity levels of head trauma along with the appropriate treatment advice is essential in deterring how critical a head trauma patient is. 

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Evidence-based Prehospital Management of Severe Traumatic Brain Injury: A Comparative Analysis of Current Clinical Practice Guidelines, Prehospital Emergency Care, Informa Healthcare

Evidence-based Prehospital Management of Severe Traumatic Brain Injury: A Comparative Analysis of Current Clinical Practice Guidelines, Prehospital Emergency Care, Informa Healthcare | Management of Severe Head Injuries | Scoop.it
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This article demonstrates the variations between different clinical procedure guidelines (CPG) in relation to the treatment of Traumatic Brain Injury (TBI).  It evaluates the evidence behind the recommendations for these guidelines. The study found 22 pre-hospital recommendations  for TBI. From twelve CPG's, variations in the reccomendations of temperature and ventilation management  for TBI seemed the most common deviant. 

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wim2_059414.pdf

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This article summarizes the New Zealand Guidelines for head injuries. It states there have been limited studies on the efficacy of pre-hospital interventions for head injury. It states there are a number of risk indicator assessment tools for acute complications associateed with TBI including the Glasgow Coma Scale (GCS). People with signs defined as risks for acute intracranial complications of TBI should be transported time critical to an emergency department. Rapid transfer is appropriate when the persons condition is deteriorating, a loss of consciousness, focal neurological deficit, skull fracture or penetrating head injury, seizure or query neck injury. It is stated, a person having a TBI should have full C-spine immobilisation attempten unless there is no alteration of consciousness, no neck pain/tenderness, no focal neurological deficit and no major distracting injury. The first priority is to treat the greatest threat to life and avoid further harm to the patient. Transport to a facility that is able to manage a traumatic brain injury in entirety is essential where possible. Paramedics must be able to determin the Glascgow  Coma Score in both adult and paediatric patints. Severe head injury is defined as a GCS of < 8. Any altered level of consciousness (ALOC) patient must have there glucose checked. The indentification and treatment of hypotension and hypoxia is primary. Identifying acute complications such as bleeding inside the skull or brain.

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Management of Severe Traumatic Brain Injury

Management of Severe Traumatic Brain Injury | Management of Severe Head Injuries | Scoop.it
In order to reduce the number of deaths from severe head injuries, systematic management is essential. This book is a practical, comprehensive guide to the treatment of patients (both adults and children) with such injuries, from the time of initial contact through to the rehabilitation center. Sections are devoted to prehospital treatment, admission and diagnostics, acute management, and neurointensive care and rehabilitation. Evidence-based recommendations are presented for each diagnostic and therapeutic measure, and tips, tricks, and pitfalls are highlighted. Throughout, the emphasis is on the provision of sound clinical advice that will maximize the likelihood of an optimal outcome. Helpful flowcharts designed for use in daily routine are also provided. The authors are all members of the Scandinavian Neurotrauma Committee and have extensive practical experience in the areas they write about.
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Sundstrom et al. (2012) state it is not recommended to use paralytics routinely to assist endotracheal intubation in patients with severe traumatic brain injury who are breathing spontaneously and maintaining an Sp02 of above 90% on supplemental oxygen. Sundstrom et al. (2012) comments on a study conducted by Chestnut et al. (1993) who proved that hypoxemia is a strong predictor in the outcome of the TBI patient. Therefore optimal oxygenation and early airway assessment is the primary concern in early treatment. Oxygen given through a bag or mask for patients with adequate respirations is sufficient. When ventilations are not adequate intubation is indicated. Sundstrom et al. (2012) reviews a study from Davis et al. (2003) which concluded endotracheal intubation performed by untrained personnel could cause harm to the patient.  Long or failed intubation as well as involuntary hyperventilation could induce cerebral ischemia. In a study conducted by Helm et al. (2006) it was found that if practitioners regularly perform the procedure and monitor both the tube position and do adequate ventilations, intubation could be performed without unwarrantable risks. Haemorrhage following trauma is the major cause of hypotension along with hypovolaemia. Haemorrhage reduces both the cerebral and peripheral oxygen delivery. This in turn increases the potential of secondary injury to the brain. Fluid resuscitation is important to support oxygen delivery and optimize cerebral haemodynamics. In the case of cerebral herniation or acute neurological deterioration, hyperventilation therapy may be necessary for brief periods. Paramedics must assess the patient frequently for signs of cerebral herniation which include dilated, asymmetric pupils, a motor exam that identifies extensor posturing or no response or progressive neurological deterioration where the patients GCS score decreases by more than 2 points from prior score of over 9. Hyperventilation is reccomended at a rate of 20 breaths per minute in an adult, 25 breaths per minute in a child and as 30 breaths per minute in an infant less than 1 year old. Capnography is preferred in the monitoring of ventilations.

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Guidelines_Management_2007w_bookmarks.pdf

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Traumatic brain injury (TBI) is a large cause of disability, death and economic cost to our society. An important concept to understand is that all neurological damage resulting from TBI evolves in the following hours and days after impact. Most treatment aims to prevent secondary injury. To cause a reduce in mortality and improve the outcomes from TBI evidence-based protocols emphasize the monitoring and maintenance of adequate cerebral perfusion. In TBI patients, systemic hypotension and hypoxemia may cause a secondary brain injury. Therefore maintenance of blood pressure and sufficient oxygenation is vital in the treatment of TBI. A significant percentage of patients with TBI have hypoxemia or hypotension in the prehospital setting as well as inhospital. Hypotension with a systolic blood pressure of less than 90 mm Hg must be corrected in TBI patients. In the prehospital setting this is achieved by administration of intravenous fluids and by raising the legs of the patient. Correction of hypoxia in TBI patients by oxygenation is crucial. Hyperosmolar agents that are currently being used for treatment of TBI are mannitol and hypertonic saline. Mannitol is widely used to control raised intracranial pressure (ICP). There is lack of evidence to reccomend prolonged use of mannitol over a period of a few days. Though single administration has been shown to have short term benefits. Hypertonic saline has been proven to control ICP. Several studies conducted have shown patients with increased intracranial pressure and TBI treated with hypertonic saline have shown improved haemodynamic parameters . There is more evidence based research on the use of hypertonic solution to effectively treat TBI than there is on the use of mannitol. With many studies conducted proving hypertonic solution as an effective treatment for increased ICP. 

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Hypothermia for acute brain injury[mdash]mechanisms and practical aspects : Abstract : Nature Reviews Neurology

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Choi, Badjatia and Mayer (2012) review therapeutic hypothermia as an effective way to prevent secondary brain injury in head trauma patients. Therapeutic cooling also known as targeted temperature management (TTM) has been increasingly used in hospital emergency departments and intensive care units. It is recommended that the body should be cooled to 33 degrees for 24 hours to minimize neurological injury after cardiac arrest.  Mild to moderate hypothermia (33 - 35 degrees) is an effective treatment for patients who have increased intra-cranial pressure (ICP), the cooling therapy can control fever in patients which have experienced trauma or hemorrhagic stroke as well as other forms of severe brain injury. It is recognized that the practice of clinically inducing hypothermia carries high risk. Management with focus to the complications relating to temperature regulation is essential in increasing the benefits of this therapeutic modality. This article investigates the neuroprotective properties that hypothermia causes for the brain. It reviews disease-specific evidence of the therapeutic effects of hypothermia on traumatic brain injury. Currently, this intervention is employed in the controlled hospital setting. In the prehospital setting practical considerations of the application of targeted temperature management  including the limited control and risk of over-cooling exist. Serial temperature monitoring in a patient undergoing this treatment is essential. Therapeutic hypothermia acts to prevent secondary brain injury by decreasing the brains oxygen demand, reducing production of neurotransmitters, especially glutamate and by reducing free radicals which are able to damage the brain. Lowering the body temperature in the prehospital field can be achieved by applying ice packs to the patient or by use of cooling blankets. In hospital more advanced methods are implemented including cooling catheters, ice water lavage and cooling helmets. By cooling the patient, risk of tissue injury is reduced from lack of blood flow. Cho, Badjatia and Mayer (2012) review an article by Davies (2005) who states there is solid evidence on the use of hypothermia for traumatic brain injury (TBI) patients. Davies (2005) also states the controversy surrounding hypothermia for TBI is important to clear up so clinicians thoroughly understand the role of all potentially therapeutic interventions. 

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