ACS TQIP BEST PRACTICES IN THE MANAGEMENT OF TRAUMATIC BRAIN INJURY Released January 2015 Table of Contents Introduction ............................................................................................... 3 Using the Glasgow Coma Scale ...................................................................... 3 Triage and Transport .................................................................................... 5 Goals of Treatment ...................................................................................... 5 Intracranial Pressure Monitoring ..................................................................... 6 Management of Intracranial Hypertension ....................................................... 9 Advanced Neuromonitoring .........................................................................12 Surgical Management .................................................................................13 Nutritional Support ....................................................................................14 Tracheostomy ............................................................................................15 Timing of Secondary Procedures ...................................................................15 Timing of Pharmacologic Venous Thromboembolism Prophylaxis ........................17 Management Considerations for Pediatric Patients with TBI ................................18 Management Considerations for Elderly Patients with TBI ...................................19 Prognostic Decision-Making and Withdrawal of Medical Support ........................20 Outcome Assessment and Quality Improvement in TBI ......................................22 Bibliography .............................................................................................24 Expert Panel ..............................................................................................28 Acknowledgements ....................................................................................29 Disclaimer .................................................................................................29 2 INTRODUCTION USING THE GLASGOW COMA SCALE Traumatic brain injury (TBI) is a disease process that carries major public health Key messages: and socioeconomic consequences. In z The Glasgow Coma Scale the United States alone, an estimated (GCS) provides a reliable tool 2.5 million emergency department visits for assessing disturbances of and hospitalizations are associated with consciousness across care paths TBI annually; and more than 50,000 individuals die from TBI. Moreover, a z Standardized approaches considerable proportion of TBI survivors to GCS assessment and incur temporary or permanent disability. reporting are essential The estimated annual burden of TBI on z The GCS should specify the score the United States economy is more than for each of the three components $76 billion, with the costs for disability (eye, verbal, motor) when and lost productivity outweighing reporting on individual patients the costs for acute medical care. z The sum of the component scores Data from well-designed, controlled (GCS 3-15) is relevant for comparisons studies on acute management of TBI are at the group level for purposes sparse. Evidence-based guidelines for TBI of classification and prognosis management have been compiled, but the paucity of high-quality studies limits The Glasgow Coma Scale (GCS) was the strength and scope of their counsel. introduced forty years ago by Teasdale The TQIP Best Practice Guidelines for and Jennett as a practical method for the Management of Traumatic Brain assessing the full spectrum of disorders Injury present recommendations of consciousness, from very mild to regarding care of the TBI patients based severe. It has been broadly adopted, and on the best available evidence or, if is internationally utilized as an integral evidence is lacking, based upon the part of clinical practice and research. consensus opinion of the expert panel. The GCS aims to rate performance in three different domains of response: the eye, verbal, and motor response (Table 1). For individual patients, it is recommended that in that all three components be reported, e.g., E4V4M5, versus a sum score, e.g., GCS 13. The derived sum score of the GCS (3-15) is more relevant for comparisons at the group level and provides a useful tool for classification and prognosis. 3 A score of ≥13 correlates with a mild of the GCS are that it covers a broad brain injury, 9 to 12 is a moderate spectrum of disorders of consciousness, injury, and ≤8 a severe brain injury. is widely applicable, and offers an important tool for monitoring changes in If a GCS component is untestable due the level of consciousness. Standardized to intubation, sedation, or another approaches to both its assessment and confounder, the reason for this should its reporting are required in order to be be recorded. Although often done, able to compare evaluations over time a score of 1 should not be assigned or when communicating with other because differentiation between a health care professionals. Spontaneous “true 1” and an untestable component responses are first observed without is relevant. Graphical display of the stimulating the patient in any way. three GCS components over time may First, verbal stimuli are applied, such as facilitate earlier detection of changes. asking a patient to obey commands and Assessment requires either a at the same time observing whether, spontaneous response or response e.g., an eye opening occurs. If a patient following application of a stimulus. is not responsive, a stimulus is applied At more severely disturbed levels of to elicit a response. The location of consciousness, the motor score has the stimulus (central or peripheral) better discrimination, but in milder should be standardized and used injuries the eye and verbal components consistently. To describe the motor are more relevant. Thus, each component response, only the reaction of the arms of the scale (Eye, Verbal, Motor) provides should be observed, not the legs. complementary information. Strengths Table 1. Glasgow Coma Scale Eye opening (E) None 1 To pressure 2 To sound 3 Spontaneous 4 Untestable Reason: Verbal response (V) None 1 Sounds 2 Words 3 Confused 4 Oriented 5 Untestable Reason: Motor response (M) None 1 Extension 2 Abnormal flexion 3 Normal flexion 4 Localizing 5 Obey commands 6 Untestable Reason: 4 Providing the initial resuscitative care TRIAGE AND in lower-level trauma center centers (III, IV, or non-designated hospitals) may TRANSPORT occasionally be rationalized in some rural Key Message settings with long transport times (≥ 1 hour). However, these hospitals should z Patients with a Glasgow Coma have predefined air/ground transfer Scale (GCS) ≤ 13 should be rapidly protocols and agreements in place to transported directly from the scene provide for the immediate transfer of to the highest level trauma center TBI patients to the highest level center available in a defined trauma system available within a defined trauma system. to allow for expedient neurosurgical assessment and intervention z Patients with a combination of TBI GOALS OF TREATMENT (GCS score ≤ 15) and moderate to severe extra-cranial anatomic injuries These clinical parameters should be and Abbreviated Injury Score (AIS) ≥3 maintained as part of goal-directed TBI should be rapidly transferred to the treatment. Some of these goals are more highest level of care within a defined relevant for patients in the intensive care trauma system to allow for expedient unit (ICU) setting (e.g., CPP, ICP, PbtO2) neurosurgical and multidisciplinary while others are applicable to all TBI assessment and intervention patients. Adequate oxygenation and normocapnia should be maintained. Proper field triage is critical for patients Patients with significant pulmonary with suspected TBI. Trauma patients issues (e.g. Acute Respiratory Distress with TBI require rapid resuscitation, Syndrome) may require lung-specific definitive operative management, and parameters. Systolic blood pressure critical care capabilities to prevent (SBP) and mean arterial pressure secondary brain injury. The US Center for should be monitored closely to avoid Disease Control’s (CDC) 2011 Field Triage hypotension. The goal for temperature Guidelines for Injured Patients direct management is normothermia. Core EMS providers to transport all patients body temperature should be kept with a Glasgow Coma Scale (GCS) < 13, <38°C. The goal for electrolytes is to or those with any level of TBI (GCS ≤ 15) maintain within normal range. Specific and extracranial injuries (AIS ≥ 3) to the attention to the sodium level is crucial highest level trauma center that has the in TBI patients. Hyponatremia must be expertise, personnel, and facilities to avoided as this may worsen cerebral rapidly provide definitive care, usually edema. TBI patients may also develop a level I or II trauma center. Despite diabetes insipidus (DI) or the syndrome these guidelines, significant undertriage of inappropriate antidiuretic hormone of TBI victims has been documented (SIADH). Therefore patients should throughout the US in systems with have frequent monitoring of the serum and without trauma centers. sodium and osmolality levels. Both 5 Table 2. Goals of Treatment Pulse Oximetry ≥ 95% ICP 20 - 25 mmHg Serum sodium 135-145 PaO2 ≥ 100 mmHg PbtO2 ≥ 15 mmHg INR ≤ 1.4 * 3 3 PaCO2 35-45 mmHg CPP ≥ 60 mmHg Platelets ≥ 75 x 10 / mm SBP ≥ 100 mmHg Temperature 36.0-38°C