[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.

145]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Indian Journal of Anaesthesia 2008; 52(3):258-263

Indian Journal of Anaesthesia, June 2008 Review Article

Prehospital Care of Traumatic Brain Injury

TVSP Murthy

Summary
Traumatic brain injury (TBI) occurs when a sudden trauma causes brain damage. Depending on the severity, outcome can be anything from complete recovery to permanent disability or death. Emergency medical services play a dominant role in provision of primary care at the site of injury. Since little can be done to reverse the initial brain damage due to trauma, attempts to prevent further brain damage and stabilize the patient before he can be brought to a specialized trauma care centre play a pivotal role in the final outcome. Recognition and early treatment of hypotension, hypoxemia, and hypoglycemia, objective neurological assessment based on GCS and pupils, and safe transport to an optimal care centre are the key elements of prehospital care of a TBI patient. Key words Traumatic brain injury, Prehospital care, Cerebral protection

Introduction
Traumatic Brain Injury is a leading cause of death and disability in children and adults in their most productive years1. This has devastating effect on lives of the injured individual and their families because disability results in a significant loss of productivity and income potential. Neurotrauma thus is a serious public health problem that mandates continuing efforts in areas of prevention and treatment. Understanding the pathophysiology of TBI has increased remarkably in the recent past. Many guidelines were established based on evidence based methodology in managing and prevention of this entity2. Issues related to treating these victims in the field or at the place of injury have lagged behind prehospital advancements in medical and general trauma management. Only in the recent past few years attempts are being made to evaluate rigorously the care provided to trauma victims in the field. Equally important to the assessment and care provided is the selection of the hospital destination. Whenever possible, the choice of a hospital should be predicated on selecting the most appropriate place for the patient to receive the care needed. In case of severe TBI, a facility, usually a trauma center, with immediate diagnosing and

intervention capabilities is the preferred direct transport destination which must have appropriate medical personnel, a CT scanner, an operating theatre, intracranial pressure monitoring, and an intensive care unit3. The issue of optimal prehospital care of the head injury is of prime importance in managing this rather challenging entity and this if addressed adequately and timely will reduce the associated morbidity and mortality to a large extent. The various issues which play a pivotal role in the prehospital management of the traumatic brain injury patient are as follows. Adequate training of the paramedics and associated health care workers on these issues will ensure a better outcome in managing this entity,

a. Hypotension and hypoxia

Early post injury episodes of hypotension and hypoxemia greatly increase morbidity and mortality from severe head injury. Evidence suggests that one should avoid and prevent values of systolic blood pressure less than 90 mmHg and oxygen saturation of less than 90%. Strong evidence suggests that patients who had these issues corrected at the site of injury had better outcomes than who had later correction4. Early oxygenation and fluid therapy will ensure avoiding this issue

Prof and Senior Adviser, Neuroanesthesiologist & Intensivist, Dept of Anesthesiology, Army Hospital (R&R), New Delhi Correspondence to: TVSP Murthy, Neuroanaesthesiology, Army Hospital (R&R) Delhi Cantt- 110010, India., Email :tvspmurthy@yahoo.com Accepted for publication on: 9.3.08 258

[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.145]||ClickheretodownloadfreeAndroidapplicationforthisjourna

TVSP Murthy. Traumatic brain injury

which will go a long way in the betterment of the injured patient.

d. Fluid resuscitation
Fluid resuscitation in patients with TBI should be administered to avoid hypotension and /or limit hypotension to the shortest duration possible. In adult trauma literature, hypotension is usually defined as a systolic blood pressure of < 90 mmHg and in children it is less than the fifth percentile for the age(< 65mm Hg for 0-1 year, <75mmHg for 2-5 yrs, <80 mm Hg for 6 -12 yrs and <90 mmHg for 13 to 16 yrs of age). Based on Class III evidence fluid therapy is utilized to support cardiovascular performance in an effort to maintain adequate cerebral perfusion pressure and limit secondary brain injury6. The most commonly used resuscitation fluid for patients of head injury is isotonic crystalloid solution. It is administered in quantities necessary to support blood pressure in the normal range. Inadequate fluid volumes or under resuscitation can precipitate sudden hypotension and should be avoided. Hypertonic resuscitation utilizing hypertonic saline has been used in prehospital setting with some encouraging results but has not been well substantiated7. No studies prove the efficacy of mannitol in prehospital setting8. Though hypotension stands as an important marker of outcome in head injured patient there has been no clear identification of parameters for field administration of fluid. Preventing shock and promptly treating hypotension are important components of TBI patient care. A single episode of hypotension has been shown to double mortality9. Even more important is measuring the cerebral perfusion pressure, but these are not measured in pre hospital setting. Vital signs such as heart rate and blood pressure are used as indirect measures of oxygen delivery in prehospital phase as well as during initial emergency department evaluation. These parameters though crude measurements, often do not correlate well with blood loss and there are no other readily available means of accurately quantifying blood loss. Autoregulation often fails following head injury, placing brain at increased risk from decrease in preload. Ideally, resuscitative in259

b. Glasgow Coma Scale

Since its introduction into clinical practice by Teasdale and Jennet in 1974, it has become the most widely used clinical measure of the severity of traumatic brain injury. It permits a repetitive and moderately reliable standardized method of reporting and recording the ongoing neurologic evaluations even when performed by a variety of health care providers. Evidence suggests that initial assessment of GCS at the site of injury by the health care worker serves as an important marker in the assessment of the progress, prognosis and outcome5. As this plays a dominant role in prehospital setting assessment of the severity of the head injury we should aim in training our paramedics in the method of application of GCS and emphasize the underlying importance.

c. Pupillary size
The pupil examination is an important component of the prehospital evaluation of patients with head trauma3. Pupillary light reflex and size reflect an indirect evidence of the pathology inside the cranial vault. It is an indirect measure of herniation or brain stem injury. Dilatation and fixation of one pupil signifies herniation, whereas bilaterally dilated and fixed pupils are consistent with brain stem injury. However, hypoxemia, hypotension, and hypothermia are also associated with dilated pupil size and abnormal reactivity making it necessary to resuscitate and stabilize the patient before assessing pupillary function. Direct trauma to the third nerve in the absence of significant intracranial injury or herniation can occur causing pupillary abnormalities, although this is usually associated with motor deficits. As this forms an important component of prehospital evaluation of patients with head trauma, all efforts should be made to educate the health care worker in correctly evaluating the pupil with emphasis on pupil size and light reflex for each eye and the duration of pupillary dilatation and fixation.

[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.145]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Indian Journal of Anaesthesia, June 2008

tervention should begin early enough to prevent a subsequent drop in blood pressure. Crystalloid fluid is utilized to augment cardiac preload, maintaining cardiac output, blood pressure and peripheral oxygen delivery. General recommendations involve the rapid infusion of 2 liters of isotonic fluid, generally Ringers lactate or normal saline as the initial fluid bolus in adults10. The goal of prehospital fluid resuscitation is to support oxygen delivery and avoid hypotension, if possible so as to avoid secondary injury.

associated with placing patients at risk for physical harm. Because patient cooperation is critical for a safe transport there are times when pharmacologic interventions, including neuromuscular blockade, are clearly indicated. Benzodiazepines and phenothiazines are commonly used drugs with range of safety in pre hospital setting.

g. Neuromuscular blockade
Studies have demonstrated the safety of using short acting neuromuscular blockade in the field to facilitate intubation performed by prehospital care providers13,14. These agents are not without risks and their use may interfere with determining the GCS score. Consequently each EMS system must carefully weigh and monitor a risk/benefit analysis of the prehospital use of sedation, analgesia and neuromuscular blockade.

e. Brain targeted therapy

Management of patients with TBI is directed at maintaining cerebral perfusion. Signs of cerebral herniation include fixed dilated pupils, asymmetric pupils, extensor posturing, or neurologic deterioration. Hyperventilation, is beneficial in the immediate management of patients demonstrating signs of cerebral herniation, but is not recommended as a prophylactic measure11. Mannitol is effective in reducing intracranial pressure and is recommended for control of ICP8. There is however no data to support its use in patients without signs of cerebral herniation and without ICP monitoring. Use of lidocaine prevents increase in ICP that occur with endotracheal intubation and its use is mandatory12 in preventing these episodes of insult on an already compromised brain pressure.

h. Managing hypoglycemia
Glucose is the primary fuel for neuronal function. Prevention of both hypoglycemia and hyperglycemia is important in the management of head injured patient as either way it can harm the patient. As hypoglycemia mimics TBI it is wise to test for glucose levels in field conditions rather than empirical dextrose administration, however when facility for testing is not available one should recognize or suspect hypoglycemia clinically and administer empiric dextrose15,16.

i. Hospital transport of the injured

The EMS personnel should effectively manage the head injured patient on the lines listed above and consider early transfer of the patient to a trauma center which is based on a number of factors including the mechanism of injury, the type and severity of the injury and the decision regarding the choice of destination. When an integrated EMS and trauma system is in place and the EMS agencies transport a patient directly from the scene of the accident to an appropriate receiving facility, the patient is entered into a system of care that has been shown to improve overall patient outcome17. Interhospital transfers of these head injury patients are known to delay the time until neurosurgical consulta260

f. Sedation and analgesia

These are the key components of comprehensive patient care and are important considerations in prehospital management. This is particularly true when long transport times are involved. The first step in managing the agitated or combative TBI patient is assessing and correcting hypotension, hypoxemia, hypoglycemia and patient discomfort. Mechanical restraints for the severely agitated patient are generally not recommended and have been

[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.145]||ClickheretodownloadfreeAndroidapplicationforthisjourna

TVSP Murthy. Traumatic brain injury

tion and intervention. This delay puts the patient at great risk for secondary insult to the brain.

Clearing the cervical spine in TBI

Cervical spine injury occurs in 510% of cases of blunt polytrauma. A missed or delayed diagnosis of cervical spine injury may be associated with permanent neurological sequelae. However, there is no consensus about the ideal evaluation and management of the potentially injured cervical spine and, despite the publication of numerous clinical guidelines, this issue remains controversial. The presence of a severe head injury increases the relative risk of a cervical spine injury, possibly by 8.5 times, and a focal neurological deficit by 58 times18. A Glasgow Coma Scale (GCS) score of < 8 is associated with a 50% increase in the incidence of cervical spine injury to 7.8%19. The prognosis in patients suffering both head and cervical injury is typically poor, with approximately 25% being discharged to a dedicated nursing facility with little prospect of recovery20. Although the vast majority of polytrauma victims will not have a cervical spine injury, the potential impact on neurological outcome if these injuries are missed requires that all polytrauma victims are managed in the expectation that injury is present .The clinical evaluation of the cervical spine assesses four parameters21. 1) Glasgow Coma Scale (GCS) = 15, and the patient is alert and orientated 2) No intoxicants or drugs have been consumed 3) No significant distracting injuries have occurred 4) No signs or symptoms on cervical examination: i) No midline tenderness or pain ii) Full range of active movement iii) No referable neurological deficit These criteria have been incorporated in American College of Surgeons Advanced Trauma Life Support (ATLS)22,23 and Eastern Association for the Surgery of Trauma (EAST) guidelines. Unfortunately,
261

polytrauma victims are more severely injured, one-third suffer head injury, and analgesia or sedation is typically required, therefore failing at least one precondition for clinically clearing the cervical spine.

Basic investigation
An anatomically and technically adequate film will visualize the cervical spine from the craniocervical junction to the cervicothoracic junction, with adequate penetration to see all vertebral bony structures and soft tissue relations. The lateral cervical plain film occupies a prestigious position within ATLS guidelines)22,23 being one of the three initial trauma screening films (lateral cervical spine, anteroposterior chest and pelvis). However, this film should never be used to clear the cervical spine due to both inadequate sensitivity and the overall poor quality of emergency films, and all polytrauma patients will require a more complete assessment. As a result of the limitations of a single lateral view in the diagnosis or exclusion of cervical spine injuries, the three view cervical trauma series (cervical series) has been developed. It has been incorporated into ATLS and EAST guidelines , and is widely recommended24 as being able to decrease the 15% of injuries missed by the lateral film alone. The cervical series comprisesa.Cross-table lateral view b. Open mouth odontoid view. This examines the craniocervical junction, ally the occipito-atlantal relations25 c. Anteroposterior (AP) view. Whenever possible, an open-mouth view also should be obtained. If the entire cervical spine can be visualized and is found to be normal, the collar can be removed after appropriate evaluation by a neurosurgeon or orthopedic surgeon. When in doubt, leave the collar on and a cervical CT scan can be obtained later.. 22,23 . Computerized tomography may reveal more fractures than plain films and may allow evaluation of the cervicothoracic and craniocervical junctions, both areas traditionally poorly visualized on plain films and with high rates of concealed injury.22

Magnetic resonance imaging

[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.145]||ClickheretodownloadfreeAndroidapplicationforthisjournal

Indian Journal of Anaesthesia, June 2008

Magnetic resonance imaging holds an undisputed position as the investigation of choice in evaluating spinal cord injuries, and has replaced conventional and CT myelography. It is recommended that any patient with a neurological deficit referable to the cervical spine should undergo plain film skeletal survey and MRI.22 Unlike plain films and CT, only MRI and dynamic fluoroscopy have the potential to directly demonstrate ligamentous pathology or instability. Since MRI is very sensitive in detecting soft tissue injury26, a number of authors advocate a normal scan as evidence of a stable cervical spine. Magnetic resonance imaging may also perform poorly at the upper cervical spine due to variation in the normal appearances of the upper ligaments, encouraging false positive results.27

In summary the health care worker should assess, stabilize and treat a TBI patient on basic resuscitation protocols that prioritize airway, breathing, and circulation assessment and treatment. Following this, assess the level of response and assess the GCS so as to categorize the severity of injury. All patients who are non responsive to painful stimulus and whose score of GCS is 39 should be planned for early evacuation to a designated trauma center which has facility for CT scan, operating suite and neurosurgical care. All the rest of the category patients should seek prompt neurosurgical opinion after initial stabilization. What ever is the severity of the injury the health care worker should emphasize caution in management so as to avoid hypotension, hypoxemia and hypoglycemia at all times for an effective outcome of the injured.

Limitations
One must consider the implications of routinely obtaining cervical MRI scans in a population of critically ill polytrauma patients. There are a limited number of scanners and typically these run during office hours. There are also severe restrictions on the availability of skilled staff to transfer, manage and image such patients, with only one-third of modern MRI units providing any regular anaesthetic sessions.28 .Most scanners are remote from the hospital main site and require an ambulance transfer, a process with well-recognized complication rates29 The ferromagnetic environment contraindicates scanning, particularly in the presence of invasive cardio respiratory monitoring and certain orthopaedic stabilization prostheses, demanding significant modification of anaesthetic and monitoring techniques30 Finally, the cost of routinely obtaining MRI scans is likely to remain high. While MRI has an undisputed role in assessing cord injuries and neurological deficits, its role in evaluating acute cervical spine trauma and mechanical stability is far from clear. Therefore, if MRI is used, it must complement plain films and CT, not replace them. The clinician must determine the likelihood of missing a cervical spine injury, particularly an isolated ligamentous injury, if the patient is mobilized while unconscious or obtunded, balancing this against the risks of immobilization.
262

References
1. Guidelines for prehospital management of traumatic brain injury: 2000 Brain Trauma Foundation, http://www2. braintrauma.org/guidelines/downloads/btf_guidelines _prehospital.pdf. Watts DD, Hanfling D. An evaluation of the use of guidelines in prehospital management of brain injury. Prehosp Emerg Care 2004;8:254-61. Tentillier E, Dupont M, Thicoipe M et al. Protocol for advanced prehospital emergency care of severe head injury. Ann Fr Aneth Reanim 2004;23:10915. Barsuk D, Ziv A, Lin G, et al. Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care. Anesth Analg 2005;100:803 -9. Davis DP, Vadebonoeur TF, Ochs M, Poste JC, Vike GM. The association between field Glasgow Coma Scale score and outcome in patients undergoing paramedic rapid sequence intubation. J Emerg Med 2005;29: 391 -7. Feldman JA, Fish S: Resuscitation fluid for a patient with head trauma and hypovolaemic shock. J Emerg Med 1991;9:465 468. Cooper DJ, Myles PS, McDermott FT, Murray LJ, Laidlaw J et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA 2004;17;291:1350-7. Duchateau FX, Burnod A, Chollet C, Ricard H A, Samain

2.

3.

4.

5.

6.

7.

8.

[Downloadedfreefromhttp://www.ijaweb.orgonTuesday,April29,2014,IP:180.247.128.145]||ClickheretodownloadfreeAndroidapplicationforthisjournal

TVSP Murthy. Traumatic brain injury

E, Marty J. Survey on the use of mannitol in prehospital care in Paris area. Ann Fr Aneth Reanim 2004;23:87993. 9. Chestnut RM, Marshall LF, Klauber MR: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34:216 222. Trauma 1993;34: 54953. 20. Davis JW, Kaups KL, Cunningham MA, et al. Routine evaluation of the cervical spine in head-injured patients with dynamic fluoroscopy: a reappraisal. Journal of Trauma 2001; 50: 10447. 21. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. Journal of Trauma 1993; 34: 3426. 22. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors student course manual. Chicago: American College of Surgeons 1997. 23. http://www.trauma.org. 24. West OC, Anbari MM, Pilgram TK, Wilson AJ. Acute cervical spine trauma: diagnostic performance of single versus three-view radiographic screening. Radiology 1997; 204: 81923. 25. El-Khoury GY, Kathol MH, Daniel WW. Imaging of acute injuries of the cervical spine: value of plain radiography, CT and MR imaging. American Journal of Roentgenology 1995; 164: 4350. 26. Holmes JF, Mirvis SE, Panacek EA, et al. Variability in computed tomography and magnetic resonance imaging in patients with cervical injuries. Journal of Trauma 2002; 53: 5249. 27. Klein GR, Vaccaro AR, Albert TJ, et al. Efficacy of magnetic resonance imaging in the evaluation of posterior cervical spine fractures. Spine 1999; 24: 7714. 28. Morris CG, McBrien ME, Farling PA. Anticipation and planning for anaesthesia provision within MR units in the UK. British Journal of Radiology 2004; 77: 216218. 29. Duke GJ, Green JV. Outcome of critically ill patients undergoing interhospital transfer. Medical Journal of Australia 2001; 174: 1225. 30. Farling PA. Anaesthesia in the magnetic resonance unit: a hazardous environment. Anaesthesia 2002; 57: 4213.

10. American College of Surgeons: Advanced Trauma Life support Instructors Manual, Chicago 1996. 11. Brain Trauma Foundation: Guidelines for the management of severe Head injury. New York. Brain Trauma foundation 1995;10:59-60. 12. Hamill J, Bedford R, etal: Lidocaine before endotracheal intubation, intravenous or laryngotracheal. Anaesthesiology 1981;155:576-578. 13. Bulger EM, Copass MK, Sabath DR, Maier RV, Jurkovich GJ. The use of neuromuscular blocking agents to facilitate prehospital intubation does not impair outcome after traumatic brain injury. J Trauma 2005;58:71823. 14. Davis DP, J Peay, MJ Sise, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma 2005;58:9339. 15. Hoffman J , Schriger D, Votey S, Luo J: The empirical use of Dextrose in patients with altered mental status: a reappraisal . Ann Emerg Med 1992;21:20-24. 16. Luber S, Brady W, Brand A, etal: Acute hypoglycaemia masquerading as head trauma: A report of four cases. Am J Emerg Med 1996;14: 543 547. 17. Sefrin P. Current level of prehospital care in severe head injury potential for improvement: Acta Neurochir Suppl (Wien) 1993; 57:141-4. 18. Blackmore CC, Emerson SS, Mann FA, Koepsell TD.Cervical spine imaging in patients with trauma: determinationof fracture risk to optimize use. Radiology 1999; 211: 75965. 19. Hills MW, Deane SA. Head injury and facial injury: is there an increased risk of cervical injury? Journal of

FAMILY BENEFIT SCHEME

The Indian Society of Anaesthesiologists through its family welfare programmes support the next kin of the deceased member of ISA to the tune of RS.10,00,000/- ! Contact : Dr.S.S.C.Chakra Rao, Secretary, Family Benefit Scheme, ISA. 67 B, Shanti Nagar, Kakinada-553003, Tel : 09440176634, Email: chakrarao@yahoo.co.in

263