INTRODUCTION

Traumatic brain injury (TBI) is one of the most significant trauma diseases of our time, with an estimated annual incidence of 1.4 million cases per year in the United States. These injuries result in upward of 50,000 deaths and 80,000 to 90,000 patients with lifelong or long-term disabilities each year.^1,² It is estimated that 5.4 million Americans are disabled owing to TBI, and the direct and indirect costs associated with this problem exceeded $50 billion dollars annually by 1995.³

Little can be done to reverse the initial traumatic insult and the resultant primary brain injury. However, secondary brain injury caused by decreased perfusion of the brain tissue can be prevented and is, therefore, the most important aspect in TBI management. Secondary injury is commonly a consequence of hypotension, hypoxia, or both. In a study of the Trauma Coma Databank,⁴ mortality rose from 25% to 75% if patients were subjected to both of these factors (Table 76-1).

Table 76-1 Outcomes after Secondary Brain Insult among Patients with Traumatic Brain Injury

Secondary Insult (N)	None to Moderate Disability (%)	Death (%)
Total patients (699)	43	37
Hypoxia (78)	45	33
Hypotension (113)	26	60
Neither (456)	51	27
Hypotension and hypoxia (52)	6	75

Adapted from Trauma Coma Databank: Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216–222.

Guidelines for management of TBI have been developed by the Brain Trauma Foundation (BTF) and the American Association for Neurological Surgery (AANS), using the best available evidence.⁵ These guidelines use the following terminology: “standards” for level 1 recommendations, “guidelines” for level 2, and “options” for level 3.

The guidelines have three standards that recommend against the use of certain previously practiced therapeutics including (1) hyperventilation, (2) use of steroids after head injury, and (3) prophylactic use of antiseizure medications to prevent late seizures. This chapter presents common TBI scenarios with management recommendations based on BTF/AANS guidelines.

SCENARIO 1

A 27-year-old man, nonhelmeted rider of a motorcycle is brought to the emergency department after colliding with a stationery vehicle. The paramedics report that the patient initially complained of something “wrong with my head” and now is verbalizing words that do not make any sense. On primary survey, his airway is clear, he has bilateral breath sounds, and his blood pressure is 101/61. Upon painful stimuli, he opens his eyes and withdraws his extremities, making incomprehensible sounds. The paramedics suspect head injury, so the patient is immediately transported to the computed tomography (CT) scanner. The trauma team is concerned about intracranial hemorrhage, “he may need to be rushed to the OR (operating room),” comments the trauma team leader. Upon arrival at the CT scanner, the patient has agonal breathing—requiring emergent intubation—and suffers several minutes of desaturation.

Did not Intubate a Patient with a Glasgow Coma Score of 8 or Less

• Consequence

Emergent airway establishment leading to hypoxemia and further brain injury.

Grade 3/4 complication

In the ABCDs of resuscitation, D is for disability, or quick neurologic examination with ascertainment of the Glasgow Coma Score (GCS) (Table 76-2). This patient has a GCS of 8 (eye opening [E] 2, verbal [V] 2, motor [M] 4). The two culprits most responsible for secondary brain injury leading to death and disability in TBI patients are hypoxia and hypotension. A patient with GCS of 8 or less must be intubated to protect the airway and prevent hypoxia. If endotracheal intubation proves to be difficult and is not achievable quickly, a cricothyroidotomy should be performed, and there should be no hesitation in establishing a surgical airway in trauma patients.

Table 76-2 Glasgow Coma Score

Score	Criterion
Eye Opening
4	Spontaneous
3	To verbal command
2	To pain
1	None
Motor
6	Obeys commands
5	Localizes pain
4	Withdraws to pain
3	Abnormal flexion to pain (decorticate)
2	Abnormal extension to pain (decerebrate)
1	None
Verbal
5	Oriented and converses
4	Confused conversation
3	Inappropriate words
2	Incomprehensible sounds
1	None