13 severe traumatic brain injury - kerala

GOVERNMENT OF KERALA

STANDARD TREATMENT GUIDELINES

DEPARTMENT OF HEALTH AND FAMILY WELFARE

SEVERE TRAUMATIC BRAIN INJURY

Committee for Development of Standard Treatment Guidelines Severe Traumatic Brain Injury

Additional Chief Secretary, Department of Health and Family Welfare, Government

of Kerala, the process of preparation of Standard Treatment Guidelines (STG) was

initiated by the Director of Medical Education Dr. Remla Beevi A. The process of

developing and finalizing the STG’s were coordinated by Dr. Sreekumari K. Joint

Director Medical education and Dr. Suma T K, Professor of Medicine and ably

supported by a dedicated team of experts, including external faculty”.

“Driven by the inspiration drawn from Shri. Rajeev Sadanandan IAS,

Convenor

Dr Rajmohan B- Prof of neurosurgery , GMC, Thiruvananthapuram

Members

1. Dr. Anil Peethambaran- Prof of neurosurgery , GMC, Thiruvananthapuram

2. Dr. Sharmad- Prof of neurosurgery and Medical Superintendent , GMC, Thiruvananthapuram

TABLE OF CONTENTS

Message by Chief Minister 7

Message by Health Minister 9

Foreword by Additional Chief Secretary 11

1. Introduction 13

2. Severe Head Injury- The Current Scenario 15

3. Brain Trauma Foundation Guidelines 19

A) Treatment Recommendations 19

B) Monitoring Recommendations 21

C) Threshold Recommendations 22

4. Limitations 23

5. Recommended Guidelines In Severe

Head Injury 24

6. Conclusions 30

7. References 31

Message

The Government is taking many initiatives to ensure providing quality

health care to all. Out of the five missions launched by the Government, the

Aardram mission is primarily focussed to improve Primary Health Care to

provide standard health care facilities to people at grassroots. This initiative is

complemented by strategic investment for the improvement of infrastructure in

secondary and tertiary health care institutions to provide quality health care

services.

I am happy to note that the Department of Health is also taking

initiatives to bring standardization in treatment for various disciplines like

Cardiology, Critical care, Diabetes Mellitus, Cancer Care, etc. It is a noteworthy

initiative to improve the qualitative aspects of the health service delivery. I

appreciate the efforts taken by the experts from Government sector and private

sector from Kerala and also the subject experts from outside the state. I am

hopeful that the introduction of standard guidelines for diagnosis and

treatment will ensure better quality and consistency in health care.

I wish all the success to this endeavour.

7

Pinarayi VijayanChief Minister

SecretariatThiruvananthapuram

Pinarayi VijayanChief Minister

Message

9

Foreword

Patient care has moved away from management by an

individual based on personal knowledge and skill to an evidence

based, team managed operation. Decisions are reviewed more

rigorously post facto and their alignment verified with standard

practice. With the mode of payment for care moving from out of

pocket payments to third party payers there will be a demand for

rigorous documentation and evidence of having conformed to

standard practice. When analysis of big data and machine learning

becomes the norm it will require a standard set of procedures to act

as the baseline from which to measure deviations and differences in

impact.

To meet the requirement of these developments in the field

of medicine, it is necessary to have explicit, objectively verifiable set

of standard operating procedures. They have to be prepared based

on international guidelines with the highest acceptance, but have to

be modified to suit local knowledge and practice, so that there is

local ownership. Government of Kerala has been trying to get the

guidelines prepared for some time now. I would like to thank and

congratulate Dr. Sreekumari, Joint Director of Medical Education

and Dr. T.K.Suma, Professor of Medicine, T.D. Medical College,

Alappuzha who took on the task of preparing standard treatment

guidelines and completed it through a long, consultative process. I

also thank the conveners of the different thematic groups who

coordinated the work in their field as well as the innumerable

number of participants, in government and private sector, who

contributed their effort and knowledge to improve the guidelines.

Professional associations have also contributed in their fields. Their

efforts have resulted in a product they and Kerala can be proud of.

Treatment guidelines cannot be static if they are to remain

relevant. They must be updated based on new knowledge and the

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experience of treatment based on these guidelines. To do this the

group which prepared the guidelines has to remain active and have

a system for collecting data on the results of practice based on

these guidelines. I hope such an activity is institutionalised and

periodic revisions of the guidelines are prepared and published.

I wish that these guidelines contribute to raising the quality of

patient care in Kerala.

Rajeev Sadanandan IAS

Addl Chief Secretary

Health & Family Welfare

Department

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Introduction

Head injury due to any cause can be a devastating incident in the life

of a person or a family that changes the whole picture of existence of the

person concerned and more often , the family concerned , especially if

the victim is the breadwinner . This is a very major problem in our society,

especially among the youth in cases of road traffic accidents, or among

middle aged or young manual labourers or climbers in workplace

accidents and athletes in sports related injuries. The overall picture is

gloomy in that the injury is to that organ of the human being, the Brain,

which makes him the person familiar to his family and associates. The

catastrophic results of Severe head trauma can vary from instantaneous

death to full functional survival through a spectrum of persistent

vegetative state, severe, moderate or mild disabilities to fully normal

individual. The persona of the victim changes as manifested by gross

alterations in behaviour, higher mental functions, speech and language

etc in some cases, so much so, that he ceases to be the individual prior to

the event.As is evident, recovery in severe head trauma is a long drawn

event, that requires prompt treatment initially, very aggressive care and

rehabilitation measures at a later stage that may include speech therapy

and physiotherapy, sometimes vocational training etc. All these are

exorbitantly expensive even in public sector health institutions. The

heavy expenditure in private sector and corporate hospitals needs no

emphasis.

An epidemiological study from NIMHANS indicates that the

incidence, mortality and case fatality rates were 150 / 100,000, 20 /

100,000 and 10 % respectiv

), followed by falls and assaults

accounting for 25% and 10% respectively. (1). Globally 50 million are

injured every year with an estimated 1.2 million deaths, a mortality of 97 /

million population, of which 70 % mortality is in the age group under 45

years. 3300 deaths and 6600 serious injuries occur every day globally

and by 2020, WHO predicts 80% increase in developing countries and

147% increase in RTA deaths in India/ Rajasthan.

In India, fatality rate of 70/10,000 vehicles is 25 times higher than in

developed countries,15-20% of TBI has alcohol as predisposing factor,

ely. (1) . Road traffic accidents contribute

60% of Traumatic Brain Injuries (TBI

STANDARD TREATMENT GUIDELINES - SEVERE TRAUMATIC BRAIN INJURY

13

giving us the dubious distinction of being the most unsafe country in the

world as far as TBI is concerned.

The high expense of treatment of TBI stems from the fact that, these

patients require prolonged Intensive Care management, costly

interventions including surgery, prolonged ventilator care, other minor

surgeries like Tracheostomy, Percutaneous Endoscopic Gastrostomy

for nutrition purposes, management of complications like Ventilator

Associated Pneumonia, Deep Venous Thrombosis, Post traumatic

epilepsy etc. And once the patient is shifted out of the ICU, starts the

much more prolonged rehabilitative procedures. Overall, the financial

burden is very high even for developed countries.

TBI can be of varying severity. From an innocuous scalp contusion or

laceration, to life threatening intraparenchymal injuries, the spectrum of

possible injuries is very wide. Scalp lacerations and degloving injuries

can cause exsanguination if not attended to in time. But these, as with

linear undisplaced skull fractures and some other innocuous fractures of

skull rarely cause severe head injury. The ones to worry about are the

major haematomas, extensive haemorrhagic contusions, extensive

parenchymal injuries, large intracranial haematomas, diffuse axonal

injury of higher grades etc. The management of these TBI requires

prompt action without delay in a coordinated manner to reduce mortality

and to provide an outcome acceptable to all. This effective management

starts from the place of injury to the time of discharge from the hospital.

The plethora of management options and drugs used in management of

severe TBI at various institutions around the world in general prompted

neurosurgical bodies to come together and attempt to produce a

guideline for their effective and uniform management worldwide. As part

of this the US Armed Forces prompted production of the Severe TBI thmanagement guidelines, 4 edition , by the Brain

Trauma Foundation, published in 2016. As is evident, this is a

guideline only and not a protocol to be used unfailingly. Protocols are to

be prepared according to the institution or state based on availability of

resources, manpower and other ancillary facilities. Ours is an attempt at

producing a Guideline for management of Severe Traumatic Brain Injury

that should be applicable for the State of Kerala.

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Severe Traumatic Brain Injury – The Current Scenario

As mentioned in the introduction, severe TBI secondary to road traffic

accidents is likely to be the most potent killer in developing countries over

the next decade. Our country and state is not exempt. With uncontrolled

proliferation of vehicles and development of roads not keeping pace with

the increase in number of vehicles, there is no doubt regarding the earlier

statement about increasing number of accidents. Poor traffic control,

disrespect for traffic rules, road rage, riding without helmets or use of seat

belts, driving under the influence of alcohol and careless pedestrians are

all causes of road traffic accidents that lead to severe TBI. Coconut tree

climbers are plenty in Kerala and falls from the tall trees causing severe

head and spine injuries are common. Similarly assaults, fall from

workplace etc are other contributory causes. A good traffic control

system with deterrent punishment to those who break the laws by itself

will bring down the rate of accidents and poor outcome associated with

it. Mortality rates in severe TBI with the best of care approaches 20 – 30

% in both the adult and paediatric population.

The management of a trauma victim starts from the point of injury.

Careless shifting of these patients can aggravate an occult cervical spine

injury leading to quadriplegia or paresis. Cervical spine injury is a

common accompaniment of these head injuries. Trained paramedics are

an important part of the trauma management team. They should be the

first to reach the accident spot and should be available for making the

patient comfortable and shifting the patient with due care to a centre

where he can be managed. Adequate care is to be taken to avoid

aggravation of any occult spine injury by use of spine boards or cevical

collar, proper maintenance of airway ensured and any site of heavy

external bleeding taken care of before shifting. IV lines can be put by

these Emergency Medical Techicians and even airway maintained till a

proper medical care is assured. With the Trauma Care Services being

improved throughout the country, the level 3 and level two centres can

give initial care and most often the maintenance care also. Very few

patients may need the support from a level 1 trauma centre.

The severely head injured patient is mostly unconscious when he

reaches the ER of a hospital. The ER staff categorises these patients on


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the basis of severity of injury and salvageability, called Triage, and starts

the treatment based on the institutional protocols. A cursory general

examination is done quickly to rule out any obvious airway compromise,

fractures of long bones, other bones, rib fractures, scalp or other

lacerations and bleeding wounds, respiration and heart rate. Any

evidence of hypovolaemic shock is noted. An intravenous access line is

placed, preferably a larger bore size, and after taking blood for routine

investigations, blood grouping, RBS, RFT and LFT; crystalloids like

Normal Saline is started. Simultaneously, a working history is elicited

from any reliable bystander regarding cause of the unconscious state,

mode of accident if any, history of seizures after the event etc. If patient is

comatose and no detailed history is forthcoming from a bystander who is

not aware of the patients prior status, a detailed clinical examination is

called for as well as more detailed blood and imaging investigations.

No head injury is considered trivial enough to be totally neglected.

The Primary injury, i.e, the injury sustained at the time of the accident or

assault cannot be modified and the outcome depends on the extent of

primary injury in a setup where the best facilities are available. It is the

Secondary Brain injury caused by other factors like Hypoxia,

Hypotension, Hyper and hypocarbia, hyper and hypothermia, other

metabolic causes etc that lead to worsening of the neurological injury and

modifies the outcome. Clinical studies indicate that upto 90% of patients

with acute TBI who require admission to the Neuro Critical Care Unit

develop Secondary Brain Injur . The aim and therefore the duty of the

attending physician is to identify these factors that can cause secondary

injury and to manage them without harm to the patient. As soon as the

patient reaches the ER, the Consultant concentrates on all these factors

and stabilises the patient. Based on the presenting status, imaging is

done at the earliest to identify the degree and type of head injury

sustained. The Consultant in ER also has to rule out associated injuries to

chest,

abdomen, long bones etc by clinical examination and imaging

modalities like a Chest Xray,

FAST USG ( Focussed Abdominal Sonography in Trauma), CT chest

whenever indicated, Xrays of long bones etc.

y(2)

16


Sometimes these may be the cause of obtundation even in mild head

injury. The clinical examination is therefore important and checking the

vital parameters like Heart rate, Blood Pressure, Respiratory rate etc may

point to unsuspected pathology.

The “Golden hour” in trauma is the initial period when the patient is

likely to go in for secondary insults to the brain like Hypoxia, hypotension

and reduced Cerebral perfusion, hyper or hypothermia etc if neglected.

This Golden hour is therefore a time for aggressive correction of these

parameters if present and a post resuscitation Glasgow Coma Scale

score at 1 hour post admission is taken as baseline.

Fractures of the skull vault can be linear undisplaced or depressed,

comminuted or fragmented and contaminated or otherwise. Any

contaminated scalp laceration or fracture has to be debrided properly to

reduce chances of worsening by infection. The fractures may also be

associated with dural and parenchymal injury in which case after a

cursory scalp suturing, patient is sent for CT head scan and surgical

debridement and repair of dural breach performed. The fractures of skull

base are notorious for producing pituitary or stalk injury if in its region

causing delayed hormonal deficiency, facial and vestibular nerve injury if

involving petrous temporal bone etc. These have to be identified by

imaging following clinical examination.

CT head scan is always preferred as first line of investigation because

of the speed of performance. Also a cervical spine screening can be done

along with brain CT in case of severe head injury. Further spine screening

is based on clinical suspicion of dorsal or lumbar fractures. When patient

is comatose and CT reveals no lesion and with biochemical tests also

negative, MRI brain may have a role in identifying severe diffuse axonal

injury or small brain stem injuries that escape detection by CT.

Haematomas associated with TBI are always picked up with the

screening CT scan and may be Acute Extradural, Acute Subdural,

Intraventricular or Intraparenchymal. Occasionally, extensive

Subarachnoid haemorrhages are also seen on CT scan. When these are

detected, the Neurosurgeon has to deal with the exigency competently.

The various modalities of treatment used are Medical and Surgical. The

patient is admitted and from the ER transferred into a specialised


17

Intensive Care setup, like a Neurosurgical ICU or Critical Care ICU where

, studies have shown that survival advantage is higher.

The mainstays of medical nonoperative management are

Osmotic diuretics, ventilation etc as practiced in our state. Medical or

Nonoperative management is mainly used for Diffuse Axonal injury,

small or medium sized haemorrhagic contusions, vault fractures

without significant parenchymal injury or intracranial haematomas,

small or medium sized haematomas intracranially which do not

produce any significant mass effect in the form of herniation or

midline shift pure intraventricular haematomas of mild to moderate

severity etc. At the other end, conservative nonoperative

management is followed for patients who are haemodynamically

compromised or with gross derangements in coagulation profile,

very advanced age with significany comorbidities like active

Coronary Artery Disease, end stage Liver or Renal disease; those

with extensive brain injury where the post resuscitation GCS is very

low, 3 or 4 with extremely low chance of functional survival etc.

Surgical management is mainly indicated in space occupying

haematomas with mass effect, younger age patients, midline shift

above 5 mm, and focal lesions. It has to be stressed that

nonoperative or Surgical management is not an end by itself; rather

only the beginning as the relatives have to aggressively support by

providing physiotherapy, speech and language therapy , emotional

support and other neuro rehabilitatory measures.

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thBrain Trauma Foundation Guidelines 4 Edition

The Brain Trauma Foundation in September 2016, published the

guidelines for the management of severe TBI, as the culmination of a

project funded in part by the US Army Contracting Command and the

Brain Trauma Foundation. They went through nearly 200 publications

that dealt with different studies related to Brain Trauma and published th

their recommendations as 4 Edition of Guidelines for management of

Severe Traumatic Brain Injury . The guidelines address treatment

interventions, monitoring and treatment thresholds that are specific to

TBI or that address a risk that is greater in patients with TBI. These

recommendations were intended to provide the foundation on which

protocols can be developed that are appropriate to different treatment

environments. There were three guidelines published previously, the last thin 2007. The 4 edition is referred to as the “Living Guidelines “ in that

ththere will not be any 5 edition, but there will only be periodic revision of

the existing guidelines by the Brain Trauma Foundation when new

studies of significance warrants it.

The BTF guidelines, as mentioned, addresses three aspects of

management; i.e; treatment interventions, monitoring thresholds

and treatment thresholds. Their recommendations in this regard are to

be incorporated into treatment protocols whenever and wherever

possible.

a) Rega rd i ng Trea tment in te rven t ions , t he ma in

recommendations are regarding Decompressive Craniectomy,

Prophylactic hypothermia, Hyperosmolar therapy, CSF

drainage, Ventilation therapies, use of Anaesthetics, analgesics

and sedatives, Steroids, Nutrition, Infection prophylaxis, Deep

Vein thrombosis prophylaxis and Seizure prophylaxis.

Decompressive Craniectomy : Recommendation based on

Level II A evidence is that a Bifrontal Decompressive

Craniectomy is not associated with any improvement in

functional outcome in diffuse injury without mass lesions, but has

an effect in reducing ICP and reducing ICU stay. However a large

Fronto Temporo Parietal Decompressive


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Craniectomy ( not less than 12 x 15 cms with a minimum diameter

of 15 cms ) has been recommended over smaller decompressive

craniectomy for better functional outcome and lesser mortality.

Prophylactic hypothermia in raised ICP ( Early hypothermia

within 2.5 hrs and short term upto 48 hrs postinjury) as well as

Therapeutic hypothermia were not found to be consistently

useful and hence is not recommended. The complications like

coagulation anomalies, cardiac arrhythmias etc preclude safe

use of this option.

Hyperosmolar therapy : Osmotic diuretics like Mannitol is useful

for reduction of ICP ( 0.25 to 1 gm/kg b.wt) but SBP has to be

maintained above 90 mm Hg. However its use in hyponatremic

states may be detrimental. The use of Hypertonic Saline is also

permitted and has an effect in the hyponatremic state, but all

studies that compared HTS 2 or 3% with Mannitol found no

survival advantage.

Cerebrospinal Fluid drainage: There was no Level 1 or II

evidence to support continuous or intermittent CSF drainage as a

measure of reducing ICP but few Class 3 studies suggested

continuous drainage keeping zero point at midbrain level in

patients with GCS below 6 but better avoided in those with better

GCS due to potentially higher mortality rates.

Ventilation Therapies : Patients with severe TBI require airway

protection to avoid aspiration and also for transient

hyperventilation to prevent brain herniation. PaCO₂ , which is

normally 35 – 45 mm Hg is required to maintain normal cerebral

perfusion in brain which is under normal ICP. If it is low, CBF

reduces and if high , CBF grossly increases (PaCO₂ within a

range of 20-80 mm Hg), worsening the ICP. Mechanical

ventilation can help to tightly regulate PaCO₂ values. Hence the

recommendation was to avoid prolonged prophylactic

hyperventilation with PaCO₂ less than 25 mm Hg. An earlier

recommendation to avoid hyperventilation in first 24 hrs

postinjury was also not supported by the current guidelines.

Anaesthetic, sedatives and Analgesics: The current guidelines do

(3)

20


not support Burst suppression in EEG using barbiturates to

reduce ICP. High dose barbiturate was however recommended

for use to control elevated ICP refractory to maximum standard

medical and surgical treatment. Propofol can also be used but

advises caution due to possibility of significant morbidity.

Steroids: Not recommended in severe TBI for reducing ICP.

Methyl Prednisolone contraindicated due to higher mortality.th th

Nutrition : Feeding patients at least by 5 day or at most by 7 day

recommended to reduce mortality. Transgastric jejunal feeding

advised to reduce incidence of Ventilator Associated Pneumonia.

Infection Prophylaxis : early Tracheostomy advised to reduce

mechanical ventilation days but not found to reduce mortality or

incidence of VAP. Povidone Iodine mouth care not recommended

as it may cause ARDS. Anti-bacterial drug impregnated catheters

may be used for EVD to reduce rate of infections.

Deep Vein Thrombosis prophylaxis: Compression stockings or

other mechanical compression devices may be used and LMWH

can also be added if brain injury is stable with little risk of

intracranial haematoma expansion.

Seizure prophylaxis : Prophylactic Phenytoin may be used to

prevent early Post traumatic seizures ( within first 7 days). Not

recommended for prevention of late PTS.

b) Monitoring Recommendations were with regard to Intracranial

Pressure Monitoring ( ICP), Cerebral Perfusion Pressure (CPP)

monitoring and Advanced Cerebral Monitoring.

ICP monitoring : ICP monitoring is recommended in severe TBI

patients and may help in decision making. Helps in reducing in-

hospital and 2 week postinjury mortality.

CPP monitoring : recommended to reduce 2 week mortality as it

helps in decision making during management.

Advanced Cerebral Monitoring : Jugular bulb monitoring of

AVDO₂ as a source for management decision making may help

to reduce mortality and improve outcomes at 3 and 6 months post

injury.


21

C. Threshold recommendations pertains to Blood Pressure, ICP

thresholds, CPP and Advanced Cerebral Monitoring thresholds.

Blood Pressure Thresholds: SBP to be maintained above 100 mm

Hg in 50 – 69 yr olds and above 110 mm Hg in 15 – 49 and above

70 year olds.

ICP Thresholds: Treating ICP above 22 mm Hg recommended as

values above this are associated with higher mortality. However, a

combination of ICP measurements, clinical and imaging findings

may be used to make management decisions.

CPP thresholds : Recommended target value of CPP for

favorable outcome is between 60 and 70 mm Hg. Aggressive

attempts with fluids and pressors not recommended for fear of

developing Adult respiratory failure.

Advanced cerebral Monitoring thresholds : Jugular Venous

saturation below 50 % to be avoided.

It has to be kept in mind that these recommendations are

applicable to severe TBI only. In Severe TBI, CVS, renal and

Hepatic functions may become greatly deranged by itself, as a

result of infections or as a sequelae of TBI; which may all interfere

with the management decisions and the practicality of

implementing the recommendations and guidelines.

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Limitations

Severe TBI is rarely an isolated event. Usually there is associated

polytrauma, either blunt or penetrating abdominal injury, chest injury,

long bone fractures etc. All these can complicate the management of

traumatic brain injury. Abdominal or chest injuries may demand priority

occasionally due to ongoing bleed. These recommendations are

therefore variable based on other factors like associated injuries etc.

Secondly many of the parameters mentioned may not be practical

everywhere. Direct CPP measurement, advanced cerebral monitoring

mentioned, and even ICP monitoring may not be practical even in some

of the bigger trauma centres of the state, purely due to nonavailability of

needed equipments and the cost thereof.

The Brain Trauma Foundation itself has mentioned that the full set of

recommendations can be applied only in high income countries.

Developing countries are the ones that have the highest rates of

vehicular proliferation and thereby accidents resulting in severe TBI. In

these countries, it may not be practical to adopt these fully due to the

financial constraints.


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Recommended Guidelines In Severe Tbi

After primary resuscitation in the Casualty or ER as it may be known

as, patient is better shifted to an Intensive Care unit preferably under the

department of Neurosurgery or Critical care anaesthesiology. Here the

monitoring starts in detail including Arterial Blood Gas analysis, ICP

monitoring if indicated and available in that centre, vital parameter

monitoring with multiparameter monitors and clinical monitoring by

elaborate head injury charts as is available. Severe TBI patients with

GCS 8 or less are deemed comatose and ideally intubated

endotracheally to keep airway open and prevent aspiration. This also

provides ease of clearing the airway and allows quick connection to the

ventilator if ABG or other investigations warrant it.

The initial imaging and clinical examination findings if indicative of life

threatening head injury, a decision regarding early surgery is made

without delay. This may be in the form of evacuation of an Acute

Extradural Haematoma or Subdural haematoma (Ac EDH or

SDH) or excision or elevation of Depressed fracture, debridement of

extensive Haemorrhagic contusions through a craniotomy etc. Rarely in

presence of severe brain oedema and evidence of brain herniation with

corroborative clinical exam findings, decision regarding emergency

Fronto temporo parietal Decompressive Craniectomy is made and

executed.

If initially, the GCS is 8 or less with severe diffuse brain oedema only

and no debridable contusion or evacuable haematoma, patient is usually

started on high dose Mannitol or other decongestant as available with

antiepileptics to avoid early seizures. Clinical monitoring of vital

parameters like heart rate, Blood pressure, pupillary size etc are charted

and progress monitored closely. For these cases as well as for those with

brain swelling and small haematomas that do not warrant evacuation

initially, a repeat CT scan of brain is indicated , usually by about 6 hours

post resuscitation. This CT usually gives an indication regarding

enlargement of haematoma or increase in brain oedema and brain

herniation, based on which decision to continue with operative or

Nonoperative management is made.

ICP monitoring is now considered a basic monitoring facility, though

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this is not available, except in very few centres of the state. The

indications are a) all patients with GCS 3-8 and abnormal scan, GCS 3-8

with normal scan and any two of the three factors,i.e; age above 40 years,

motor posturing or systolic BP < 90 mmHg. It is indicated in those with

GCS 9 -15 when there is a bleed,extra axial > 1 cm thick,temporal

contusion or an ICH > 3 cm, with effaced basal cisterns and midline shift >

5 mm. ICP monitoring is recommended in cases after a craniotomy and

when patient is not in a position to be examined neurologically ( sedated,

after surgery etc) Icp monitoring is done with a host of transducers,

the most preferred being intraventricular. External Ventricular Drainage

can also be done from this location. The preferred technique now being

continuous rather than intermittent drainage with zero at the midbrain

level. However there is a risk of infection through the EVD ( 5-20 %)

Mechanical Ventilation in the Neuro Intensive Care is primarily to

decrease ICP which increases in presence of hypoxia ( PaO₂ < 60 mm

Hg). Irreversible changes start after PaO₂ falls below 30 mm Hg.

Survival time of various tissues in presence of hypoxia ranges from the

most sensitive brain ( 3 minutes) through the Kidney and Liver ( 15 -20

minutes), skeletal muscle (60 – 90 minutes) to hair and nails ( several

days). Weaning has to be done early when the patient improves

clinically. Early tracheostomy is indicated now to lessen the chances of

aspiration, ventilator associated Pneumonia and especially for ease of

tracheo bronchial toilet.

The aim of surgery is primarily to save the life of the victim and

secondarily a good functional recovery with least permanent disability.

Severe TBI are associated with multiple fractures which may involve the

skull vault, air sinuses, skull base and pituitary fossa or petrous or

mastoid bone, rarely the Craniovertebral junction etc.

The initial surgery may be able to manage some of these. The patient

may be haemodynamically compromised due to blood loss, preexisting

cardiac illness etc. They have to be quickly identified, their situation

corrected and based on neurological clinical or imageological

assessment, dealt with by surgery or otherwise.

Decompressive surgery is recommended as a life saving procedure

(4).

(5)

(6).

(7).


25

as well as to provide space for the brain to adjust in the oedematous stage

immediately after an acute TBI. It has been found to improve survival

though the functional outcome is not encouraging When a

Decompressive Craniectomy is to be performed, the current

recommendations prefer a large Fronto temporo parietal Craniectomy of

15 x 12 cms size with a minimum diameter 15 cms. Post recovery, this

vault defect can be repaired with either custom made inplants of MRI

compatible material or as practiced in our centre with the same bone flap

kept in the anterior abdominal wall.

An accepted step care regimen for Severe TBI in adults would be as

mentioned by Hari Hara Dash et al, which is as follows-

l If GCS is < 8 and ICP > 22 mm Hg

l peripheral and central venous cannulation, either subclavian or

IJV

l Secure airway and ensure adequate ventilation

l head of Bed elevated to 30 degree if not contraindicated by spine

fractures.

l Analgesics and sedation and Neuromuscular blockade as

required

l PaCO₂ to be 25 – 30 mm Hg in initial phase in severe oedema for

short term and then to be stabilised between 35 - 40 mm Hg with

ABG monitoring to avoid worsening of neurological status.

l External ventricular Drainage to provide access for CSF drainage

and ICP measurement.

l Osmotic Diuretics like Mannitol at 0.25 – 1.0 gm / kg b. Wt or 3 %

Hypertonic

l Saline(HTS) at 3-5cc/kg and brief hyperventilation if ICP>22

mm Hg persistently.

l If ICP rise is still refractory, a large flap Decompressive

Craniectomy is done to salvage life.

l Though Barbiturate induced EEG burst suppression and

Hypothermia are now not recommended, some authors still

advise them to be used for very refractory ICP rise.

In children, there are differences with respect to the steps of care,

thresholds etc. Adelson PD and team in Paediatric Critical Care, 2003

( 8).

(9)

(

26


10) has given detailed description of thresholds recommended for severe

TBI management in children, most of which can be practiced in our state

also. The main points that can be used here are as follows-

The initial procedures are the same as in adults with resuscitation,

stabilisation, examination for other system injuries and emergency

management of penetrating or blunt abdomen and chest injuries,

insertion of peripheral and central venous catheters etc.

l Analgesia/sedation: As per Sedation and Analgesia Protocol.

Phenobarbitone (10mg/kg boluses, maximum 30-40mg/kg) may

be a useful adjunct for sedation and ICP control.

l Ventilation: Maintain adequate oxygenation to keep SPO₂ >

94% and low normal

l CO2. Volume control ventilation is preferred. PaCO2 is to be

correlated to monitored EtCO2. Parameters preferred to be

maintained are PaCO2 4.7 - 5.3 kPa , PaO2 > 10.7 kPa

l Circulation: Hypotension should be managed quickly as it

compromises cerebral blood flow and doubles mortality and

morbidity. Hypotension is rarely due to head injury except in

severe brain stem compromise and so should always prompt

search for occult bleeding and other causes. Manipulate MAP to

achieve target cerebral perfusion pressure for age. Generally this

will mean a MAP: children below 2 years > 55 mm Hg; 2 - 6 years

> 60 mm Hg ; above 6 years > 70 mm Hg. These goals are for

avoiding hypotension prior to insertion of an ICP monitor or if

there is no ICP monitor. Once the ICP monitor has been inserted,

MAP will follow from the ICP/CPP goals. CVP maintained at 5 –

12 cms H₂ O and noradrenaline can be used for hypotension

after CVP correction with crystalloids.

l Fluid/glucose management. Give 75% of normal maintenance

as isotonic saline with sufficient potassium to maintain

normokalaemia. Blood glucose should be within normal levels

and needs no supplementation by IV route in first 48 hours

unless the blood glucose is less than 4.4 mmol/L in those below 2

years, and less than 3.9 mmol/L in those above 2 years of age.


27

After 48 hours dextrose may be added as per IV fluid protocol, but

may not be necessary if feeding has started. If the blood glucose

is > 11mmol/L on two occasions, insulin should be used to control

the blood glucose. Frusemide is avoided during the first 5 days

unless clinically significant fluid overload (i.e. pulmonary oedema)

occurs.

l Sodium & Osmolality: Maintain serum sodium > 140mmol a n d

serum osmolality above 280mOsm/kg. If sodium drops below

140mmol/l, fluids are restricted to 30-50% maintenance and

hypertonic saline (3mls/kg of 3% saline) given over 1 hour via

central venous access.

l ICP/CPP goals: Age (years) ICP (mmHg) CPP (mmHg)

< 6 < 18 >45 - 55

≥ 6 < 20 >50 - 60

l A CPP of >40 mmHg may be acceptable for children ≤ 2 years

old. An ICP ≤ 25 mm Hg with a preserved CPP despte first tier

treatments may be tolerated for longer periods (eg 5-15 minutes )

especially after the first 2-3 days.

l ICP monitoring, Anticonvulsant use with Phenytoin in first week,

Nutrition etc are all as with adult head trauma.

It has however be specially emphasised that ICP monitoring, CBF

measurement at the bedside and some other recommendations cannot

be uniformly enforced in our state or the country due to non availability of

required equipments in health care institutions, except few Trauma

centres, and the prohibitive cost of disposable items required thereof.

No two cases are alike. Hence, each brain trauma patient, by his own

status at presentation and by the radiological and clinical exam findings,

determine the action to be taken in his or her case. A trauma victim who is

admitted with poor post resuscitation score of 3 or 4 may not benefit from

an emergency surgery, especially if there are signs of brain stem

dysfunction. Such patients are as a policy, ventilated and managed with

decongestants. The mortality rate is very high in these patients and

usually do not respond to treatment.

An algorithm for management of severe TBI is attached, as is

28


Re

cep

tion

, T

ria

ge

Sp

ine

Bo

ard

, rig

id c

erv

ica

l co

llar,

a

irw

ay

cle

ara

nce

Prim

ary

Re

susc

itatio

n:

airw

ay,

Bre

ath

ing

an

d c

ircu

latio

n;

Vita

ls a

sse

ssm

en

t,

Co

rre

ctio

n o

f H

ypo

xia

, H

ypo

ten

sio

n a

nd

hyp

ovo

lem

ia;

En

do

tra

che

al i

ntu

ba

tion

, I

nte

rco

sta

l tu

be

dra

ina

ge

if c

he

st in

jury

. R

ea

sse

ssm

en

t o

f G

CS

aft

er

resu

scita

tion

GC

S a

fte

r re

susc

itatio

n 3

-4,

ve

ntil

atio

n a

nd

su

pp

ort

ive

ca

re o

nly

.G

CS

=/<

8,

CT

sc

an

, C

T

cerv

ica

l sp

ine

, X

ray

che

st,

FA

ST.

Pt

imp

rove

s o

n

ven

tila

tion

& a

nti

oe

de

ma

m

ea

sure

sC

T s

ho

ws

Ac.

ED

H,

SD

H,

ICH

, S

AH

, o

pe

n c

om

min

ute

d

de

pre

sse

d #

sku

ll, L

arg

e

H'h

ag

ic c

on

tusi

on

, b

urs

t lo

be

etc

Diff

use

Bra

in O

ed

em

a

with

mid

line

sh

ift <

5m

m

If A

nis

oco

ria

+,

Bra

dyc

ard

ia a

nd

hyp

ert

en

sio

n p

rese

nt:

IV M

an

nito

l 0.5

– 1

.0 g

m/k

gb

wt

as

bo

lus,

IV

Ph

en

yto

in

18

mg

/kg

bw

t a

t 5

0 m

g/m

t

ICP

mo

nito

rin

g,

an

tioe

de

ma

me

asu

res

an

d

an

tiep

ilep

tics

if si

ze o

f b

lee

d is

sm

all

an

d n

o g

ross

ma

ss e

ffe

ct.

DV

T p

rop

hy

lax

is,

Ea

rly

E

nte

ral

fee

din

g w

ith

NG

T

or

PE

G a

fte

r fe

w d

ay

s,

Ca

re o

f c

he

st

an

d b

lad

de

r,

tre

atm

en

t o

f a

ss

oc

iate

d

infe

cti

on

s.

Ea

rly

an

d a

gg

res

siv

e r

eh

ab

m

ea

su

res

aft

er

pt

imp

rov

es

.

If b

lee

d is

larg

e, A

C E

DH

> 3

0 m

ls s

up

rate

nto

ria

lly o

r A

c S

DH

with

ML

S >

5 m

m,

fo

reig

n b

od

y in

bra

in ,

e

me

rge

ncy

su

rge

ry f

or

eva

cn o

f b

lee

d /

de

com

pre

ssio

n

If I

CP

pe

rsis

ts a

bo

ve 2

0-2

5 m

m H

g,

an

d r

efr

act

ory

to

ve

ntil

atio

n a

nd

a

ntio

ed

em

a m

ea

sure

s, R

ep

ea

t C

T -

-If

siz

e o

f le

sio

n h

as ↑

, su

rge

ry f

or

eva

cn o

f b

lee

d o

r D

eco

mp

ress

ive

cr

an

iect

om

y.

practiced in many centres of the state. Minor variations based on

availability of scarce resources may be there from centre to centre but we

hope that this can serve as a treatment guideline for severe TBI for the

state of Kerala.

TR

EA

TM

EN

T A

LG

OR

ITH

M F

OR

SE

VE

RE

TR

AU

MA

TIC

HE

AD

IN

JU

RY

(S

EV

ER

E T

BI)


29

Conclusions

Severe TBI is a major catastrophe for the victim and his family, which

not only deprives the family of an earning member or loved one, but also

plunges the family into an extremely emotional and financial crisis. Many

families belonging to the poorer socioeconomic status find themselves

unable to support such a victim. The public sector health care system

alone will not be able to cope up with all the TBI cases in the state. Other

than in Eranakulam General hospital, there are no neurosurgeons in the

government hospitals other than Medical colleges. There was a great gap

in resources between the corporate sector and the public sector

regarding available facilities which has markedly come down. Still the

charges vary to a great extent.

As far as management protocols are concerned, there are only minor

differences among the neurosurgeons of the state. The patients survival

with the best functional outcome possible is the priority of everyone. A

unified treatment guidelines acceptable to all and practiced uniformly as

much as the situation in each individual case allows, is the objective of

this exercise. The algorithm presented is one which is practiced in Govt

Medical College, Thiruvananthapuram . The recommendations from the th

BTF 4 edition Guidelines can be incorporated to this as much as possible

to make it more attractive and scientifically acceptable.

For survivors of Severe TBI, the most important factor that

determines their outcome is availability of expert Neurorehabilitatory

care, which unfortunately is not available in the state now. People who

can afford still depend on either NIMHANS or CMC, Vellore for neuro

rehab support. Initiatives in this regard is essential to make the

management of TBI fully successful.

30


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-

32


Annexe II, Secretariat Thiruvananthapuram

Kerala-695001

Department Of Health And Fa ily WelfaremGovernment Of Kerala

Ke HEALTHrala

Feb

rua

ry 2

021

13 severe traumatic brain injury - kerala

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