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Approach to the Acutely Brain Injured Patient (Nonoperative Management)

Clinical History || Physical Exam || Initial Testing || Management
Related Articles || References and Resources || Comment

Managing a patient with acute traumatic brain injury (TBI) can be very stressful. However, by following a logical series of steps it may be possible to drastically alter the patient's overall prognosis.

Clinical History

The first step is to obtain some clinical history. It is important to get a description of how the injury occurred. Was it a high speed motor vehicle accident? Were seat belts used? Did they fall from a significant height? What were the circumstances surrounding the accident? Were alcohol or drugs involved? Does the patient have a history of seizures? Was a seizure witnessed? What was the patient's Glasgow coma scale (GCS) when the paramedics arrived on scene? And was spinal immobilization utilized (many head injuries also have co-existent spine injuries)?

In addition, a quick trauma history should always be taken. This includes the following important questions, also known as the "AMPLE" history:

(1) A -> Allergies
(2) M -> Medications (especially anticoagulants/anti-platelets)
(3) P -> Past medical history
(4) L -> Last meal (especially if surgery is indicated emergently)
(5) E -> Events (see above)

In the acutely brain injured person some of this information may be missing since the patient may be non-communicative. If a family member or friend is present try to get as much information as possible.

Physical Exam

We will neglect the rest of the body for the sake of this discussion and focus on the neurological exam. However, remember to always follow the "ABCs" (airway, breathing, circulation) with any traumatically injured patient.

The neurological exam in an acutely brain injured patient should focus on the GCS score, pupillary, and spinal cord exams.

The GCS is an important indicator of the patient's overall level of consciousness. It can be used to follow a patient's clinical course throughout their hospitalization.

GCS Severity
8 or less

Severe

9-13

Moderate

14-15

Mild

The pupillary exam is an extremely important part of the neuro check in a brain injured patient. An asymmetrically enlarged pupil (aka: a "blown pupil", see image below) could indicate that part of the brain is herniating due to increased intracranial pressure (see the Monro-Kellie doctrine article). This increased pressure could be due to bleeding in the brain (ie: subdural or epidural hematomas) or generalized edema (ie: swelling) secondary to the injury. Bilaterally fixed and dilated pupils portend a very poor prognosis.

Blown Pupil

Head trauma is commonly associated with spine trauma. Therefore, it is important to do a thorough neurological exam by checking the spine for tenderness and assessing both motor and sensory functions. Decreased motor and/or sensory (ie: light touch, pin prick, hot, cold, proprioception) abilities in the extremities could indicate spinal cord injury.

Initial Laboratory and Imaging Tests

The most important initial study in the head injured patient is a CT of the head without contrast. This will show any acute process like intracranial bleeding that may need emergency surgery. In addition, a CT (or plain films) of the cervical spine can also be obtained to assess bony spinal column injury.

Additional tests include a urine and blood toxin screen. This information may provide clues for why the injury occurred. It is also important later to prevent agitation from possible withdrawal (ie: delirium tremens).

Blood tests should include prothrombin time (PT), and activated partial thromboplastin time (aPTT). These will help determine if the patient is coagulopathic. In addition, a type and screen should always be ordered on any trauma patient in case resuscitation with blood products, or operative management becomes necessary. A complete metabolic panel (CMP) and complete blood count (CBC) are also routinely ordered.

Additional imaging may include MRI of the brain to assess for diffuse axonal injury (DAI). This devastating form of injury is not typically seen on CT scans. MRI of the spine may also be necessary to assess for ligamentous injury of the spine if the initial CT (or plain films) is read as normal, but the patient is still deemed at high risk for spine injury.

Non-Operative Management

Non-operative management is dictated by several factors. The GCS score, presence of raised intracranial pressure, and the type of injuries dictate how the patient is managed in the ICU.

Patients with a GCS of 14-15 (ie: "mild" injuries) are usually admitted to the hospital for observation. Neurological exams should happen every two to four hours. IV fluids (isotonic saline) should be started. Pain and nausea control with medications like acetaminophen (aka: Tylenol®) and ondansetron (aka: Zofran®) should also be administered. The patient can often be allowed to eat, especially if they are alert and oriented. However, there should be a low threshold for repeating a head CT if the patient appears to be getting worse.

Patients with a GCS of 9-13 (ie: "moderate" injuries) are admitted to the ICU. Neurological exams should occur at least every two hours. In addition to the above the patient should be made "NPO" (ie: nothing by mouth) in case they need to be taken to the operating room. Many physicians order a routine repeat head CT six hours after admission; however, a repeat CT should be done immediately if the patient's clinical status worsens. Depending on how mobile the patient is deep venous thrombosis prophylaxis may be warranted.

Patients with a GCS of 8 or less (ie: "severe" injuries) are admitted to the ICU with hourly neurological exams. The patient should be made "NPO". In addition to all of the above, these patients often have intracranial pressure monitors placed by a neurosurgeon. A monitor is recommended if the GCS is < 8 and they have an abnormal head CT or if the head CT is normal, but they have two or more of the following: age > 40 years, systolic blood pressure < 90 mmHg, or posturing movements. Controlling pain and agitation is important because it helps decrease intracranial pressure; therefore, judicious use of narcotics for pain and sedatives for agitation are indicated. In addition, since these patients are often immobile for a long period of time they should have some form of deep venous thrombosis (DVT) prevention once their head CT findings are stable.

References and Resources

(1) Blackbourne LH. Surgical Recall, Fifth North American Edition (Recall Series). Fifth Edition. Philadelphia: Lippincott Williams and Wilkins, 2009.

(2) Frontera JA. Decision Making in Neurocritical Care. First Edition. New York: Thieme, 2009.

(3) Simon RP, Aminoff MJ, Greenberg DA. Clinical Neurology, Seventh Edition (LANGE Clinical Medicine). Seventh Edition. New York: McGraw Hill, 2009.

(4) Greenberg MS. Handbook of Neurosurgery. Sixth Edition. New York: Thieme, 2006. Chapter 25.

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