TBI Pearls

Presentation and buzz words:

• TBI, Traumatic 

• Often will come up from trauma bay or operating room.

• What was the mechanism of injury? GSW? MVC? Fall?

One liner:

• When presenting the one liner, note the day of trauma, biggest injury and what that makes today. Note any interventions patient had, if ICP/EVD monitor in place, and any course complications. 

• Example: "Trauma day was 12/3. Today is post-trauma day 1 from large subdural hematoma and the patient is post-op day 0 from clot evacuation. ICP monitor in place and course complicated by ARDS."

Diagnose etiology:

• Often our patients are found down or don't remember details of injury. 

  • • • Send work up to try to figure out why accident happened. Sometimes it is just mechanical, but make sure.

        • • • Syncope? Review telemetry, check carotids for significant stenosis and order echocardiogram.

            • Infection? Send basic infection work up

            • Check CK and urine to monitor for rhabdomyolysis if found down.

            • Alcohol or polysubstance use? When was last drink?

              • • At risk for withdrawal. Monitor vitals and consider phenobarbital. Phenobarbital is preferred over CIWA/ativan in the ICU setting.

                • Start thiamine, folate, multivitamins. 

• Review ED imaging:

  • • • Non-contrast head CT scan is the initial imaging modality of choice.

        • • • Most common locations for TBI are the bilateral frontal lobes, bilateral anterior temporal lobes, diffuse axonal injury 

      • Do we have stability of hemorrhage? Repeat CTH typically done in 4-6h 

      • Do they have any coagulopathy to correct? 

        • • • Consider checking platelet assays or sending a TEG

      • Non-contrast C-spine to assess for spine injury

TBI ICU course/possible complications

• "Blossoming" of contusions: expansion of contusion to parenchymal hemorrhage

• Edema: global or perihematomal

• Increased intracranial pressure or decreased cerebral compliance

• Impaired autoregulation

• Blunt cerebrovascular Injury (BCVI) - diagnosed by CTA 

• Seizures 

• Storming (aka paroxysmal sympathetic hyperactivity) can occur with loss of inhibitory control of sympathetic nervous system.

Severity Scores

• Note Glasgow Coma Scale (GCS)

  • • • Classify TBI into:

        • • • Mild (13-15), moderate (9-12), or severe (3-8) categories.

• Note Biffle Grade for BCVI (Grade I-V)

#TBI Plan Guidance

• Note mechanism and note every type of brain injury - ex: subdural, epidural, SAH, etc.

• Note etiology if known or work up pending 

• If C-Collar in place, note findings of CT C-spine and clearance plan

• Note any surgical interventions done

• Note if intracranial monitor, ICP or external ventricular drain (EVD) in place 

  • • • Note ICP waveform for compliant or non-compliant brain

      • Note ICP rage over 24 hours

      • Note if ICP elevations happen with stimulation or spontaneous

• q1h neuro checks. Consider liberalizing or offering a sleep holiday as appropriate.

• Systolic blood pressure typically <140, but should be individualized to your patient. 

• Seizure prophylaxis for 7 days - typically done with Keppra given low side effect profile

• Consider cEEG if patient's scan does not match patient's symptoms

• Sodium goals are based whether there is edema or non compliant brain. 

• When ICP monitoring with ICPm or EVD, aim for ICP ≤22 and CPP 60-70 mmHg.

  • • • CPP = MAP - ICP

• Maintain euvolemia, normothermia, normoglycemia.

• Avoid hypoxia or profound anemia 

• Ensure vascular assessment for vascular injury with CTA head and neck 

• DVT ppx may be started 24h after stability of CTH or OR. Ensure no additional intervention needed that day. 

Medications:

• Review home meds. 

  • • • Hold antiplatelets or anticoagulation and review indication to discuss risk benefit to restart 

• Sedation and analgesia: what is the weaning plan for any drips?