Outline the strategies, with the rationale, to reduce the likelihood of secondary neurological injury after brain trauma. Give the specific parameters/targets where appropriate.
Strategy |
Rationale |
Endotracheal intubation |
Prevention of hypoxaemia by preventing airway obstruction and/or aspiration, facilitates mechanical ventilation |
Controlled mechanical ventilation O2 saturation >95% PaCO2 32 – 38 mmHg (4.2 – 5.0 kPa) |
Avoidance of hypoxaemia, Avoidance of hypercarbia which can lead to cerebral vasodilation and increased ICP Avoidance of hypocarbia with consequent cerebral vasoconstriction and relative ischaemia |
Cervical spine immobilisation |
Cervical spine injury is commonly associated with traumatic brain injury |
Maintain an adequate blood pressure Systolic BP >110 MAP 80-120 if CPP measured and ICP>20 |
Hypotension is associated with poorer neurological outcome Hypovolaemia is common in trauma patients due to associated injuries |
Avoid the use of albumin for fluid resuscitation |
Albumin is associated with poorer outcomes in patients with TBI |
Avoid cerebral venous hypertension Care with ETT tapes C-spine collars Elevate head of bed 30-45o |
Obstructed venous drainage can contribute to intracranial hypertension |
Maintain normothermia Temperature 36-37o |
Elevated temperature increases cerebral metabolic demand Hypothermia has not yet been shown to be associated with improved outcomes |
Maintain normoglycaemia BSL 6-10 mMol/L |
Hypoglycaemia exacerbates cerebral injury |
Avoid hyponatraemia Na 140-145 mMol/L |
Hyponatraemia can contribute to cerebral oedema and raised intracranial pressure |
Early detection of surgically correctable secondary lesion ICP monitoring Low threshold for repeat CT scan if deterioration in clinical neurological state |
Early identification of a surgically correctable lesion Reaccumulation of extra-axial collection Hydrocephalus New intraparenchymal haemorrhage Surgical intervention may prevent further neurological damage |
Monitoring of and treatment for intracranial hypertension ICP <20 |
Strategies to treat intracranial hypertension (in addition to those mentioned above) Sedation Neuromuscular paralysis Induction of mild hyperosmolar state |
Detect and treat seizures |
Convulsive and non-convulsive epileptic seizures, increase cerebral metabolic demand |
Neuroprotective measures in traumatic brain injury are discussed in great detail elsewhere.
Other chapters of interest would have to include
In brief:
Maintaining cerebral oxygen supply:
Decreasing cerebral oxygen demand:
Controversial measures: