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Airway management

• Intubation should occur if the patient is unable to maintain an adequate airway, oxygen saturation 94-98% or has a GCS under 9.
• It is essential to avoid hypoxia and hypercapnia.
• Hyperventilation should be avoided, except in unusual circumstances in which prior consultation via ARV is advised.
• Aim to keep the end-tidal carbon dioxide (ETCO₂) reading around 35–40 mmHg. Blood gas analysis should be used to assist setting ventilation parameters (if available) and if so, target PaCO2 35-40 (noting correlation with ETCO₂) ⁽²⁴⁾.
• ETCO₂ monitoring (if available) should also be used to assess respiratory status and the adequacy of ventilation. Always have emergency airway equipment by the bedside.

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CT scan/x-ray/FAST

CT scan

• CT scanning is the preferred method of imaging if available and should be performed early in the severe to moderate TBI group. Except for an uncomplicated minor head injury, ideally all patients with a significant head injury should have a CT scan.
• If it appears that the patient will require transfer to a MTS, the decision as to whether to conduct a CT prior to retrieval must be considered.
• Any critical trauma patient must be very closely monitored while in the CT scanner.
• Definite indications for CT scanning include:
  • GCS ≤ 12 on initial assessment in the Emergency Department
  • GCS < 15 at the 2 hour point after injury, on assessment in the Emergency Department.
  • GCS ≤ 9 after resuscitation.
  • Neurological deterioration.
  • > 1 episode of emesis.
  • Focal neurological deficit (pupil inequality, change in reactivity such as dilated pupils of unreactive on one side, hemiparesis of the limbs).
  • Skull fracture – known or suspected.
  • Penetrating injury – known or suspected.
  • Age over 50 years following trauma due to increased risk of injury.
  • Post-operative assessment such as emergency burr hole evacuation.
  • Seizure activity.
  • Other risk factors such as chronic liver disease or the use of anticoagulants.

X-ray

• In situations where CT facilities are unavailable or do not exist, then the use of plain skull x-rays can be considered, although not ideal or the current standard.
• They should not delay a retrieval consultation or transfer.
• If performed the views required are lateral, anteroposterior and Towne’s and a view tangential to the point of impact to show a depressed fracture.
• Ensure cervical spine x-rays and CT is performed.

eFAST

• Consider the need for eFAST if available and if staff are trained in its use. In haemodynamically stable patients, eFAST can be delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed ^{(11, 26)}.

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Tranexamic Acid (TXA)

X-ray

The early administration of TXA in patients with severe TBI is recommended ^{(27, 28)}.

• Administered within 3 hours of insult.
• Consult ARV for further guidance.

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The intoxicated patient with head trauma

• Difficulties arise with accurate assessment of the GCS in patients who present with potential head trauma and intoxication due to alcohol or prescribed or illicit medications. The reliability of the GCS can be made problematic, particularly in the eye-opening component. Assuming that an altered conscious state is due only to intoxication is particularly risky and places the patient and clinician at risk ^{(25, 29)}.
• CT imaging of the brain and cervical spine is recommended in all patients who are intoxicated and have signs of an injury to the head. Agitated patients with signs of head injury may require sedation and intubation to facilitate appropriate management with CT imaging. CT of the facial bones may also be required where there is evidence of facial injuries.
• Intoxicated patients without signs of head injury should be observed until they are clinically not intoxicated. If there is still doubt in relation to a brain/spine injury at this stage based on clinical examination, then CT imaging should be performed.
• This is a high-risk cohort for intracranial injury. These patients are at risk of missed chronic and acute on chronic subdural haematomas.
• While these patients can be challenging to care for in the emergency department, it is vital to maintain close observation and prevent any further injury from occurring. Consultation with regional hospitals, trauma services or ARV may be appropriate to obtain advice or where necessary to arrange transfer or retrieval.

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Anticoagulation and head trauma

• Any patient who is taking an anticoagulant such as warfarin or other oral anticoagulants (dabigatran, rivaroxaban, apixaban) is at substantial risk of developing a significant intracranial haemorrhage from minor head injury mechanisms. CT imaging of the brain should be performed on all patients with a history of head injury.
• Platelet inhibitor therapy (aspirin (e.g., Astrix, Cartia), dipyridamole (Asasantin, Persantin), clopidogrel (Iscover, Plavix), prasugrel (Effient), ticagrelor (Brilinta)) also increases the risk for haemorrhagic injuries but to a lesser degree.
• These patients often have significant comorbidities also, all of which will have a direct impact on surgical and intensive care decision making and treatment. The effects of anticoagulation and antiplatelet drugs may require their reversal, with consideration of the risks of exacerbation of the underlying condition.
• Where intracranial haemorrhage is present, patients on anticoagulation medication may deteriorate because of the extension of their bleed leading to mass effect, brain compression, and herniation. In these patients, reversal of medications should be commenced with appropriate reversal agents. Consultation with ARV should take place prior to administration.
• For immediate reversal of anticoagulation in patients with bleeding due to warfarin, prothrombin complex concentrates (Prothrombinex-VF in Australia) are preferred over fresh frozen plasma (FFP) ⁽³⁰⁾.
• Fresh frozen plasma (FFP) is not routinely needed in combination with prothrombin complex concentrates (PCC) unless there is life-threatening bleeding. If life-threatening bleeding is present the dose of FFP is 150–300 mL by IV infusion. Where Prothrombinex-VF is unavailable the dose for FFP is 15 mL/kg IV infusion. Time is required for determining the patient’s blood type (or use group AB plasma), thawing of the product and subsequent infusion.
• Vitamin K is essential for sustaining the reversal achieved by PCC or FFP. IV administration produces a more rapid response than oral administration in the short term. The dose is 5–10 mg IV.
• Specialist haematological advice should be sought for guidance on reversal of anticoagulation due to new novel anticoagulants such as dabigatran, rivaroxaban, and apixaban. For such patients, consult with MTS emergency, trauma, and haematology staff via ARV.
• Idarucizumab is a monoclonal antibody fragment which binds free and thrombin-bound dabigatran and neutralises its activity, resulting in complete reversal of the anticoagulant effect. Its effect is immediate and lasts for 24 hours ⁽³¹⁾. It may not be available in all facilities, so in consultation with ARV and the MTS, there may be the possibility of prearranged reversal agents being taken to site for administration by retrieval staff in urgent situations.

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Patient positioning

In the initial acute resuscitation, it is best to maintain the patient in a supine position. If there is a delay in transferring the patient to a MTS or metropolitan neurological service and the patient has an adequate volume and hypotension is not an ongoing problem, nor are there concerns for thoracolumbar injury then consideration can be given to adjusting the position.

• Elevating the head of the bed by 30% while maintaining a neutral spine alignment has been shown to reduce ICP without significantly changing cerebral blood flow. It also aids in promotion of venous drainage.

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Seizure Prophylaxis

Anticonvulsants are indicated in the early stages following severe TBI in order to reduce the incidence of seizures, and their subsequent sequelae ^{(16, 32)}. Prior to prophylactic treatment, specific guidance from ARV and/or the receiving neurosurgical facility should occur.

• Phenytoin is recommended to decrease the incidence of early post traumatic seizures (within 7 days of injury) when the overall benefit is thought to outweigh the complications of such treatment. At the present time there is insufficient evidence to recommend Levetiracetam (Keppra) compared with Phenytoin regarding efficacy in preventing early post traumatic seizures and toxicity ⁽¹⁶⁾.
• In patients with prolonged seizures, midazolam or diazepam should be administered in addition to phenytoin. Ongoing seizure activity increases the likelihood of secondary brain injury.

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Pathology tests

In a ventilated patient, arterial blood gases (ABG) provide valuable information, especially in an intubated patient. Ventilation targets should be based on blood gas analysis and adjusted accordingly, aiming for a PaCO2 of 35–40 mmHg and a Sa02 94-98%.

FBC, UEC, glucose and coagulation studies should be obtained for all patients who meet the definition of severe head injury or confirmed intracranial haemorrhage. Consider blood group and crossmatch as well if the patient is involved in a trauma presentation with a high index of suspicion for further injuries.

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Thermoregulation

Prevention of thermal extremes is the goal in initial management of TBI. A rise in core body temperature is common in the first few days after injury, which can then increase the likelihood of secondary brain injury due to a rise in ICP and carbon dioxide production. Hypothermia should also be avoided as it may aggravate acute traumatic coagulopathy seen in the multi-trauma patient.

• Goals of care revolve around avoidance of hyperthermia, instead of prophylactic hypothermia. There is no current conclusive evidence to support prophylactic hypothermia as a means to improve morbidity and mortality ^{(16, 33, 34)}.

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Analgesia

For patients suffering a head injury, analgesia should be carefully considered. The drug of choice will be considerate upon clinical signs, the need for analgesia and the provider’s skilled decision making.

When using opiates, it is important to adequately monitor the patient’s neurological status; titrate the dose so it is effective in pain management but also so that it does not make determining the GCS almost impossible. Short-acting agents are the best choice; avoid continuous infusions at this stage. Pupil size and reactivity can be affected by the administration of opiates and barbiturates, therefore they can become unreliable.

• Providing a dark and quiet environment can also help an agitated patient though this is not often able to be achieved in the emergency environment.
• Consider antiemetics at this stage, especially if transfer and retrieval is likely.

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Sedation

Drowsy, confused, or agitated TBI patients should not be sedated in the initial resuscitation. It makes assessment of their GCS difficult and can alter their response to examination, complicating assessment, and diagnosis.

• However, in the setting of a patient being unmanageable, risks of injury to staff, or delaying urgent required management, then sedation with appropriate medications is authorized. Consult with ARV if unsure at any stage.

In a ventilated patient, however, paralysis and sedation are essential to management. Appropriate sedation may lower ICP by reducing metabolic demand. Further beneficial effects of sedation include a reduction in hypertension and tachycardia as well as improved patient– ventilator synchrony.

• Propofol and Midazolam have become widely used as sedative agents with neurological injuries ⁽³⁵⁾. Clinician decision regarding best medication for patient is suitable, and consult with ARV if required.

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Monitoring

SBP should remain above 110 mmHg and Sp02 between 94-98% to avoid secondary brain injury ⁽¹⁶⁾.

• Monitoring of the heart rate, respiration rate, blood pressure, and oxygen saturation should take place at 15-minute intervals or less if indicated.
• All monitoring should be maintained until the retrieval team arrives. A baseline ECG should be taken if time permits and facilities exist prior to transfer.
• Placement of an arterial line (if possible) is highly valuable in providing real time monitoring of blood pressure to reduce secondary brain injury due to hypotension. It also allows for close monitoring of haemodynamics by the retrieval clinician throughout the retrieval process.
• If an arterial line is inserted, a MAP target >80 will replace the SBP target.

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Wound care

Initial management of the wound in the emergency department is aimed toward controlling bleeding with either bandaging or direct external pressure. If bleeding is unable to be controlled, then stapling or suturing the wound may be required as a form of temporary closure. Discussion with ARV and a neurosurgical specialist should take place to guide treatment.

• In a patient with a moderate to severe TBI with an open wound, it is best to leave definitive treatment to the care of the neurosurgical facility upon transfer. The wound will require exploration and debridement.

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In-dwelling catheter

A urinary catheter should be inserted in the patient with a severe head injury and urine output measured hourly. A urinalysis should be performed also to check for blood. The desired urine output for adults is 0.5–1.0 mL/kg/hr.

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Nasogastric tube

All patients should be kept nil orally in the initial post-resuscitation phase of injury. The placement of a nasogastric tube in head injury cases is controversial due to the risk of possible intracranial insertion.

In suspected base of skull fractures or with any maxillofacial injuries, insertion should be avoided until the patient is transferred to the neurosurgical centre. Alternatively, an orogastric tube can be placed under careful direct visualisation.

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Tetanus immunisation

Tetanus prophylaxis should be administered in any penetrating brain injury patients and in those with multi-trauma with open wounds ⁽³⁶⁾.

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Antibiotics

The risk of local wound infections is particularly high in patients with a penetrating injury due to the presence of contaminated foreign objects such as skin, hair and bone fragments ⁽³⁷⁾.

• Routine prophylactic treatment with antibiotics for open and penetrating head injuries is not currently indicated ⁽³⁸⁾. Consultation with ARV or the MTS is recommended.

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Steroids

Corticosteroid treatment is not recommended in the acute management of TBI ^{(16, 39)}.

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Reassess

The importance of frequent reassessment cannot be overemphasised. Deterioration in a patient’s neurological status can be swift, leading to devastating further secondary brain injury if delay in recognition. Patients should be re-evaluated at regular intervals as guided by the clinician. GCS ideally should be performed every 15/60 in moderate to severe head injury cases. If in doubt about any aspect of patient care, repeat <C> ABCDE.

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Additional management points for the rapidly deteriorating patient

There are situations where the patient presenting with a TBI will rapidly deteriorate prior to arrival at a MTS or neurosurgical facility. This is more likely to occur in rural and remote locations, however, is also relevant for metropolitan facilities.

The following flowchart is based on: Neurosurgical Society of Australasia. The management of acute neurotrauma in rural and remote locations. Version 2. 2009.

If considering the below, contact ARV to speak with a trauma service and neurosurgical specialist for advice. Each of the above recommendations will be discussed in the following section.

Assume brainstem herniation

Assume brainstem herniation in an unresponsive (comatose) patient with:

• Bilateral dilated unresponsive pupils or unilateral dilated unresponsive pupils and abnormal extension (decerebrate posturing) or no motor response to painful stimuli.

If signs of herniation

• Hyperventilate with an aim for a PaCO₂ of 30 mmHg. Monitor the response with ETCO2 readings or ABG.

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Hyperventilation

Hyperventilation to a PaCO₂ of 30 mmHg helps lower ICP by causing cerebral vasoconstriction and lowering cerebral blood flow. Prolonged hyperventilation may actually produce cerebral ischemia and so it should be used in moderation and for as short a duration as possible ⁽¹⁶⁾.

• Ideally, consultation via ARV with a trauma service and neurosurgeon prior to hyperventilation therapy is recommended.

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Osmotherapy

Intravenous solutions that exert an osmotic effect, such as mannitol 20% and hypertonic saline solution 3% (HTS) have been the mainstay of treatment for many years.

• Cautious use of these therapies is advised and should only be considered as a rescue intervention when signs of herniation are present or rapid neurological deterioration is evident.
• Historically mannitol was the standard choice, however, HTS has shown equivalent efficacy and a more sustained result ^(40-43).
• There is no Level I or Level II evidence at this stage to state which therapy has a better outcome in patients with severe TBI ⁽⁴⁴⁾. The decision as to which treatment is used may reflect the availability of each and the preference of the specialist neurosurgeon.

All dosing regimens should be conducted in consultation with ARV and the receiving neurosurgical facility.

A large IVC should be inserted as well as an -indwelling catheter in order to closely monitor fluid output and response to therapy.

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Burr hole evacuation

Emergency burr hole craniotomy may be necessary where time to definitive care is prolonged. This procedure is especially important in a patient that is rapidly deteriorating and does not respond to non-surgical measures.

The decision to conduct burr hole evacuation is based on:

• Estimated transfer time.
• Clinical state – level of consciousness, pupillary size, and light reflex.
• Rate of deterioration.
• CT scan (if available) or x-ray of skull.
• Level of surgical experience and range of neurosurgical equipment available at the regional hospital.