ACS TQIP Severe TBI Guidelines

Traumatic brain injury (TBI) is a disease process that carries major public health and socioeconomic consequences. In the United States alone, an estimated 2. 5 million emergency department visits and hospitalizations are associated with TBI annually; and more than 50,000 individuals die from TBI. Moreover, a considerable proportion of TBI survivors incur temporary or permanent disability. The estimated annual burden of TBI on the United States economy is more than $76 billion, with the costs for disability and lost productivity outweighing the costs for acute medical care. Data from well-designed, controlled studies on acute management of TBI are sparse.

Evidence-based guidelines for TBI management have been compiled, but the paucity of high-quality studies limits the strength and scope of their counsel. The TQIP Best Practice Guidelines for the Management of Traumatic Brain Injury present recommendations regarding care of the TBI patients based on the best available evidence or, if evidence is lacking, based upon the consensus opinion of the expert panel.

Key messages: zz The Glasgow Coma Scale (GCS) provides a reliable tool for assessing disturbances of consciousness across care paths zz Standardized approaches to GCS assessment and reporting are essential zz The GCS should specify the score for each of the three components (eye, verbal, motor) when reporting on individual patients zz The sum of the component scores (GCS 3-15) is relevant for comparisons at the group level for purposes of classification and prognosis The Glasgow Coma Scale (GCS) was introduced forty years ago by Teasdale and Jennett as a practical method for assessing the full spectrum of disorders of consciousness, from very mild to severe.

It has been broadly adopted, and is internationally utilized as an integral part of clinical practice and research. 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. A score of ≥13 correlates with a mild brain injury, 9 to 12 is a moderate injury, and ≤8 a severe brain injury.

of the GCS are that it covers a broad spectrum of disorders of consciousness, is widely applicable, and offers an important tool for monitoring changes in the level of consciousness. Standardized approaches to both its assessment and its reporting are required in order to be able to compare evaluations over time or when communicating with other health care professionals. Spontaneous responses are first observed without stimulating the patient in any way. First, verbal stimuli are applied, such as asking a patient to obey commands and at the same time observing whether, e. g. , an eye opening occurs. If a patient is not responsive, a stimulus is applied to elicit a response.

The location of the stimulus (central or peripheral) should be standardized and used consistently. To describe the motor response, only the reaction of the arms should be observed, not the legs. If a GCS component is untestable due to intubation, sedation, or another confounder, the reason for this should be recorded. Although often done, a score of 1 should not be assigned because differentiation between a “true 1” and an untestable component is relevant. Graphical display of the three GCS components over time may facilitate earlier detection of changes. Assessment requires either a spontaneous response or response following application of a stimulus.

At more severely disturbed levels of consciousness, the motor score has better discrimination, but in milder injuries the eye and verbal components are more relevant. Thus, each component of the scale (Eye, Verbal, Motor) provides complementary information. Strengths Eye opening (E) None To pressure To sound Spontaneous Untestable Verbal response (V) None Sounds Words Confused Oriented Untestable Motor response (M) None Extension Abnormal flexion Normal flexion Localizing Obey commands Untestable Table 1. Glasgow Coma Scale

Key Message zz Patients with a Glasgow Coma Scale (GCS) ≤ 13 should be rapidly transported directly from the scene to the highest level trauma center available in a defined trauma system to allow for expedient neurosurgical assessment and intervention zz Patients with a combination of TBI (GCS score ≤ 15) and moderate to severe extra-cranial anatomic injuries and Abbreviated Injury Score (AIS) ≥3 should be rapidly transferred to the highest level of care within a defined trauma system to allow for expedient neurosurgical and multidisciplinary assessment and intervention Proper field triage is critical for patients with suspected TBI.

Trauma patients with TBI require rapid resuscitation, definitive operative management, and critical care capabilities to prevent secondary brain injury. The US Center for Disease Control’s (CDC) 2011 Field Triage Guidelines for Injured Patients direct EMS providers to transport all patients with a Glasgow Coma Scale (GCS) < 13, or those with any level of TBI (GCS ≤ 15) and extracranial injuries (AIS ≥ 3) to the highest level trauma center that has the expertise, personnel, and facilities to rapidly provide definitive care, usually a level I or II trauma center. Despite these guidelines, significant undertriage of TBI victims has been documented throughout the US in systems with and without trauma centers.

Providing the initial resuscitative care in lower-level trauma center centers (III, IV, or non-designated hospitals) may occasionally be rationalized in some rural settings with long transport times (≥ 1 hour). However, these hospitals should have predefined air/ground transfer protocols and agreements in place to provide for the immediate transfer of TBI patients to the highest level center available within a defined trauma system.

These clinical parameters should be maintained as part of goal-directed TBI treatment. Some of these goals are more relevant for patients in the intensive care unit (ICU) setting (e. g. , CPP, ICP, PbtO2) while others are applicable to all TBI patients. Adequate oxygenation and normocapnia should be maintained. Patients with significant pulmonary issues (e. g. Acute Respiratory Distress Syndrome) may require lung-specific parameters. Systolic blood pressure (SBP) and mean arterial pressure should be monitored closely to avoid hypotension. The goal for temperature management is normothermia. Core body temperature should be kept <38°C. The goal for electrolytes is to maintain within normal range.

Specific attention to the sodium level is crucial in TBI patients. Hyponatremia must be avoided as this may worsen cerebral edema. TBI patients may also develop diabetes insipidus (DI) or the syndrome of inappropriate antidiuretic hormone (SIADH). Therefore patients should have frequent monitoring of the serum sodium and osmolality levels. Both 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 PaCO2 35-45 mmHg CPP ≥ 60 mmHg * Platelets ≥ 75 x 103 / mm3 SBP ≥ 100 mmHg Temperature 36. 0-38°C Hemoglobin ≥ 7 g/dl PH 7. 35-7.

45 Glucose 80-180 mg/dL PaO2: partial pressure of oxygen; PaCO2: partial pressure of carbon dioxide; SBP: systolic blood pressure; ICP: intracranial pressure; PbtO2: brain tissue oxygen tension; CPP: cerebral perfusion pressure; INR: international normalized ratio; *depending on status of cerebral autoregulation hyperglycemia and hypoglycemia are detrimental to the outcome of patients with TBI. Serum glucose levels must be monitored closely in all TBI patients. More frequent monitoring is required following the initiation of nutritional support, particularly in patients with known or suspected diabetes mellitus. Anemia and coagulopathy are common in patients with TBI and should be monitored closely.

There is considerable practice variability in hemoglobin transfusion thresholds for TBI patients. A recent randomized clinical trial compared 2 hemoglobin transfusion thresholds (7 and 10 g/dl) after TBI. There were no differences in neurological outcome.

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