Question

a) what medical intervention would be indicated for TBI (focal brain injury)? for each medical intervention describe

B) what are the benefits of each type of medical intervention ?

Answer 1

TRAUMATIC BRAIN INJURY

Traumatic Brain Injury (TBI) is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.

Medical management of TBI include:

1. Using GLASGOW COMA SCALE
2. PREHOSPITAL TRIAGE AND TRANSPORT
3. MANAGEMENT IN INTENSIVE CARE UNIT which includes:

• INTRACRANIAL PRESSURE MONITORING
• MANAGEMENT OF INTRACRANIAL HYPERTENSION
• ADVANCED NEURO MONITORING
• NUTRITIONAL SUPPORT
• TRACHEOSTOMY
• VENOUS THROMBOEMBOLISM PROPHYLAXIS

​​​​​​​1. USING GLASGOW COMA SCALE

• the GCS provides a reliable tool for assessing disturbances of consciousness across care paths
• standardized approaches to GCS assessment and reporting are essential
• the GCS should specify the score for each of the 3 components when reporting on individual patients
• the sum of the component scores (GCS: 3-15) is relevant for comparison at the group level for purposes of classifications and prognosis.

​​​​​​​2. TRIAGE & TRANSPORT

• Patients with a GCS less than or equal to 13 should be rapidly transported directly from the scene to the highest level trauma centre available in a defined trauma system to allow for expedient neurosurgical assessment and intervention
• patients with a combination of TBI and moderate to severe extracranial anatomic injuries and Abbreviated Injury Score(AIS) greater than or equal to 3 should be rapidly transferred to the highest level of care

3. GOALS OF THE TREATMENT

PULSE OXIMETRY GREATER THAN OR EQUAL TO 95%	ICP 20-25 mmHg	SERUM SODIUM 135-145
PaO2 greater than or equal to 100mmHg	PbtO2 greater than equal to 15mmHg	INR less than or equal to 1.4
PaCO2 35-45 mmHg	CPP greater than or equal to 60mmHg	PLATELETS greater than or equal to 75 x 1000/mm3
SBP greater than or equal to 100 mmHg	Temperature 36.0-38 degree celsius	HAEMOGLOBIN greater than or equal to 7gm/dL
Ph 7.35-7.45	GLUCOSE 80-180mg/dL

4. ICP MONITORING

• ICP monitoring is important, but it does not replace the careful neurological and radiographic examination
• ICP monitoring is indicated in comatose patients where GCS is less than or equal to 8 and if there is evidence of structural brain damage on initial CT imaging
• the preferred method for ICP monitoring is an external ventricular drain because it is both diagnostic measure (measures ICP) and therapeutic (allows for drainage of CSF)
• Along with CEREBRALMPERFUSION PRESSURE (CPP), ICP monitoring can provide advanced warning of impending structural brain arrangements such as contusion/hematoma progression, increased cerebral oedema and postoperative complications

​​​​​​​5. MANAGEMENT OF INTRACRANIAL HYPERTENSION

• the recommended 3 tiered approaches to ICP management utilizes various treatments to target different mechanisms.
• repeat CT imaging and neurological examination should be considered to rule out the development of surgical lesion and guide management.

​​​​​​​6. ADVANCED NEURO MONITORING

• advanced neuromonitoring and assessment of cerebral autoregulation may be helpful in identifying a more individualized approach to treatment
• impaired cerebral oxygenation can occur in the face of normal ICP & CPP
• cerebrovascular pressure reactivity index and cerebral blood flow monitoring can assess autoregulation status, which may help determine patient -specific CPP & ICP GOALS

​​​​​​​7. NUTRITIONAL SUPPORT

• nutrition should begin early, as soon as the patient is thermodynamically stable and ideally within 24-48hrs of injury
• enteral nutrition is recommended over the use of parenteral nutrition
• post pyloric feeding methods are preferred as they are associated with a lower rate of pneumonia

​​​​​​​8. TRACHEOSTOMY

• If level of consciousness remains persistently depressed, TBI patients should undergo tracheostomy to facilitate liberation from mechanical ventilation; this can decrease the risk of pneumonia and ventilator induced ling injury

​​​​​​​9. VENOUS THROMBOEMBOLISM PROPHYLAXIS (VTE prophylaxis)

• Ptients with TBI are at high-risk for venous thromboembolism
• VTE prophylaxis should be considered within the first 72 hours following TBI in most patients. earlier initiation of pharmacologic prophylaxis appears to be safe in patient at low risk for progression of intracranial bleeding and have stable repeat head CT scan

​​​​​​​THESE ARE THE MEDICAL MANAGEMENT MEASURES FOR TRAUMATIC BRAIN INJURY