Traumatic Brain Injury

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Introduction

Traumatic brain injury, also known as head injury or intracranial injury is the result of physical trauma causing brain damage and can
result from a closed or penetrating head injury. It is classified as mild, moderate or severe and can also be divided into two separate categories; primary and secondary brain injury.

Clinical Presentation

Mechanism or pattern of injury suggesting head trauma.
Abnormal behaviour or deteriorating mental status / abnormal neurological exam:
- Asymmetric or non-reactive pupils
- Visual disturbances/headaches
- Seizures
Possible CSF leakage
Periorbital / retroauricular bruising (Raccoon eyes / Battle’s sign)
Indicators of raised ICP:
- Systolic hypertension / widening pulse pressure
- Bradycardia, abnormal respirations. i.e. “Cushing’s triad”.

Exclusion Criteria

Risk Assessment

Primary injury is generally irreversible therefore the aim of treatment is to prevent secondary injury by supporting cerebral haemodynamics and metabolism. Hypoxia and hypotension cause the most prominent secondary injuries and may more than double mortality.
Hyperventilation should be avoided as it exacerbates cerebral ischaemia and can reduce venous return. It is generally used as a last resort where signs of impending cerebral herniation are evident.
Exercise caution when considering Nasopharyngeal Airway during treatment of a patient with a suspected base of skull fracture.

Management

Primary Care

Primary Survey with c-spine consideration
Be aware of Trauma Management Principles
Manage catastrophic bleeding (with haemorrhage control as required)
Airway management/ventilatory support (as required)
Oxygen therapy as per CPG (maintaining SpO₂ above 90%)
Secondary / CNS Survey
Position patient with 30° head elevation if condition permits to improve venous drainage
Contraindication
- Do not use 30° elevation in the hypovolemic patient

Intermediate Care (EMT / Level 2)

Administer pain relief
Consider applying cardiac monitor if trained and authorised
Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
Transport Priority 1 if patient time critical, pre-notifying receiving facility

Advanced Care (AP)

Establish vascular access
Use fluid therapy to manage and prevent hypotension (SBP <90mmHg)
Main euglycaemia (BGL > 4mmol/L) with IV Glucose 10% as required
Apply cardiac monitoring
Consider pain relief
Consider Ondansetron
Consider Ketamine for patients exhibiting combative TBI
Consider advanced airway management as required
Metropolitan crews should consider Major Trauma Bypass as per guideline
Monitor patient persistently, recording full observations every 5 minutes
Transport patient Priority 1 if patient time critical, pre-notifying receiving facility

Critical & Extended Care (CCP, PSO)

Additional Information

References

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