Traumatic Brain Injury
Les Galler
Outline
DCCM General Approach to TBI Patients
• Patient with TBI is a trauma patient whose injuries include the head
• Needs multi-disciplinary initial evaluation of all injuries
• Control of extra-cranial factors vital to optimise milieu for injured brain
• Vital to avoid hypotension, have good oxygenation, & control of haemorrhage
• “1st priority for the TBI patient is complete and rapid physiologic resuscitation”
Brain Orientated Intensive Care “Package”
• Blood Pressure - MAP 90-110mmHg
• Good oxygenation
• Good ventilation - pCO2 of 35-40mm Hg
• Avoid pyrexia - Maintain temp of 36 +/- 1 deg C
• Sedation/Neuromuscular Blockade to control ICP rises
• Head up posture/neutral neck position
• Normovolaemia with controlled hypersomolality (290-300mmol/L - serum Na 140-145)
• “Zero” tier Rx - the basic treatment “package”
Critical Pathway for Treatment of Raised ICP
Alcohol is commonly involved
• 79% had blood alcohol measured
• 54% had zero blood alcohol but
46% had blood alcohol 4 – 112, median 42 mmol/l
Number and Type of Craniectomy
ICU stay – non-survivors who had treatment withdrawn for brain damage
Prognostication and Decision-making in TBI Patients
• Treatment/triage decisions based on assessment of:
– Initial clinical presentation
– CT scan and other imaging eg MRI
– SEP’s
– Sedative-free clinical assessment
– Consensus decision-making
• Withdrawal of Rx for anticipated severe brain damage occurs with:
– Medical consensus to withdraw Rx (Intensivists/Neurosurgeons)
– Full ongoing honest communication with family
• The “Death” word mentioned early
• Avoidance of medical jargon
• Use of “translators”
• Consistent messages
– Family not asked to make decisions but asked to have consensus with process
– Emphasis on maintenance of dignity and comfort, relief of distress
Summary
• TBI is a disease of young men
– Alcohol, road crash, falls and violence
– Intensive medical and surgical treatments
• With high mortality (27% in this series)
– Often after treatment withdrawn for brain damage
• The direct costs of treatment are high
– ICU and neurosurgical infrastructure
– Later hospital and rehabilitation costs
• Survivors are often variably disabled
– Long-term social and financial costs
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Ministry
of Health
