PRACTICE GUIDELINE

Effective Date: 8-20-04 Manual Reference: Deaconess Trauma Services

TITLE: MANAGEMENT OF TRAUMATIC BRAIN INJURY

PURPOSE: To provide guidelines to help standardize the diagnosis and early management of
traumatic brain injury.

DEFINITION: Traumatic brain injury: An injury to the brain resulting in disorders of motor,
sensory and/or cognitive function.

GUIDELINES:

1. Perform primary survey according to ATLS guidelines:

a. Consider using lidocaine with intubation (IV and topical).
b. Maintain C-spine precautions including rigid collar.
c. Provide urgent airway for GCS ≤ 8, hypoxia can be devastating to the injured
brain.
d. If sedatives and paralytics are to be used, conduct a rapid but thorough
neurologic exam, including:
i. Level of consciousness.
ii. Ability to verbalize.
iii. Ability to open eyes.
iv. Ability to move all extremities to verbal command or pain.
v. Presence of abnormal posturing.
vi. Presence of abnormal reflexes.
vii. Presence of rectal tone if unable to move lower extremities.
viii. Pupillary response.
ix. Gag reflex.
x. Note presence of bruises, Battle’s signs, lacerations, etc.
e. Check for chest injury, ventilate to maintain mild hypocapnia (pCO2 = 35 to
40 mmHg).
f. Determine hemodynamic status, resuscitate from shock with lactated ringers
solution. Maintain normovolemia and normal hemodynamics.
g. Expose patient, when able, to look for any non-obvious injury.
2. Resuscitate patient as above until hemodynamic and pulmonary stability is achieved.
3. Calculate the Glasgow Coma Scale.
4. Consider need for neurosurgical consult.
a. Head CT abnormality.
b. Any patient with GCS <12.
c. Any patient with focal neurologic deficit.
d. Any patient with unequal pupils secondary to brain injury.
5. Obtain a head CT scan:
a. GCS ≤14.
b. Any patient with focal neurologic deficit.

1
 c. Any patient with witnessed loss of consciousness >5 minutes.
6. CT priorities:
a. CT should be abandoned if patient requires emergent operation to stop
hemorrhage or immediately repair life-threatening injury. Notify neurosurgery
immediately of this situation.
b. CT should be obtained, otherwise, to determine presence of space-occupying
clot prior to other surgeries.
7. Sedation:
a. Uncooperative or thrashing patients should be treated with sedation. Page
neurosurgery STAT for evaluation.
i. Morphine 0.1 mg/kg IV if associated with painful injury.
ii. Versed 0.075 mg/kg IV for agitation.
iii. If intubated, Pancuronium 0.1 mg/kg IV or cisatracurium 0.2 mg/kg
IV, if sedation is not satisfactory, to allow ventilatory control or
cooperation with the diagnostic studies. Do not give paralyzing agent
without associated pain medications or sedative.
8. Hyperventilation: mild hyperventilation may be used, trying to achieve a pCO2 of ≈35-40
mmHg.
9. Seizures:
a. Consider seizure prophylaxis:
i. Administer if seizure has occurred.
ii. Administer if there is a high likelihood of post-traumatic seizure.
a) Penetrating injury.
b) Skull fracture with depression.
c) Intraparenchymal hematoma.
10. Mannitol: at the discretion of the neurosurgeon, a mannitol bolus of 1 gm/kg can be
given for evidence of rising intracranial pressure.
11. Remember: a craniotomy can be performed at the same time as other operative
procedure. Consider all possibilities if patient is being taken to the OR.
12. Scalp lacerations:
a. Exsanguinating hemorrhage can arise from scalp lacerations.
b. Rainey clips are available in the trauma room and may be used to temporarily
control bleeding from large scalp avulsions.
13. Notify IOPO if GCS < or = 5.

REFERENCES:

ƒ Deaconess Trauma Guideline Manual, ENDOTRACHEAL INTUBATION AND

AIRWAY MANAGEMENT.
ƒ Deaconess Trauma Guideline Manual, BRAIN INJURY & CEREBRAL
PERFUSION PRESSURE.
ƒ
REVIEWED DATE REVISED DATE
JAN 05 JAN 08

2
JAN 06
JAN 07