Emergency Treatment for Traumatic Brain Injury: From First Responders to the Neurointensive ICU

This article reviews the current best practices for the diagnosis, treatment, and prognosis of TBI and the dual diagnosis of TBI and a spinal cord injury (SCI). We will also discuss who is on the medical team, and the types of hospitals equipped and prepared to treat severe brain injuries.

In the last two decades, there have been dramatic advancements in the care of patients diagnosed with TBI. Medical research has led to developments in diagnosis, testing, and treatment, which have in turn led to recommended standardized treatment (guidelines). The practice of evidence-based medicine, which simply means using the best available knowledge based on clinical research and from clinical medical practice, has contributed to these advancements.

Advancements in the Diagnosis and Treatment of TBI

The Brain Trauma Foundation (BTF) updated its guidelines for the treatment and care of severe TBI in 2016.¹ That said, hospitals have different capabilities due, in part, to the availability of specialists and technology, and some hospitals may not be in the position to follow evidence-based best practices for the treatment for TBI.

Note that the guidelines and standard of care pertinent to severe TBI are also relevant to moderate TBI (sometimes referred to as potentially severe TBI).

Evaluation and Treatment by Emergency Responders

The primary goal of emergency or prehospital management for moderate and severe TBI is to prevent and treat low blood pressure (hypotension) and insufficient oxygen (hypoxia) caused by the initial brain injury. The aim is to avoid further brain injury (a secondary injury) caused by the body’s reaction to the initial injury. These secondary brain injuries can be caused by low blood pressure, insufficient oxygen, and other systemic events. For example, if the first injury to the brain is caused by a car crash, a second brain injury can occur if there is a lack of sufficient oxygen getting to the brain caused by low blood pressure, insufficient oxygen, or both. The moderate to severely injured brain is very vulnerable to any secondary injury that may occur in the first 24 hours after the initial injury. Medical evidence indicates that when the supply of oxygen and blood pressure are normalized, it leads to improved outcomes for patients.^{2, 3, 4}

Airway Management by Emergency Responders

Evidence based medicine recommends an intubation procedure for patients with moderate to severe brain injury, as needed. Intubation enables the patient to breathe if they cannot do so on their own. It is a lifesaving procedure. An emergency medical technician (EMT) places a small tube (an endotracheal tube or ETT) into the mouth or nose, past the windpipe (trachea) which is the tube that allows air into the lungs. The ETT is used to make sure air can get in and out of the lungs easily. The more experienced the emergency responders are in airway management of critically ill patients, the better the outcome. If intubation is not available or possible for any reason, then bag-mask ventilation may be the only alternative.^{5, 6}

Blood Pressure Management by Emergency Responders

Prevention of low blood pressure before arrival at the hospital is important. To do this the EMTs provide fluids and medications by directly injecting them into a person’s vein. This IV therapy is used to increase the blood pressure.⁷

Neurologic Assessment by Emergency Responders

EMTs should always assume that patients with TBI could have a spinal fracture, and the EMTs should take appropriate precautions to stabilize and immobilize the spine during transport. A prehospital assessment using the Glasgow Coma Scale can be helpful for early triage decisions in the hospital emergency department. Triage is a process in which the seriousness of the injuries is ranked in terms of importance or priority.

Evaluation and Treatment in the Emergency Department

Not all hospitals are created equally. Some hospitals are not prepared to treat life-threatening brain injuries because they do not have the necessary medical specialists and equipment. Where the patient receives treatment for a moderate or severe brain injury can make a difference between life and death. EMTs or paramedics typically decide where to transport the patient after assessment. Patients with a moderate to severe brain injury should be transported to a hospital that has a trauma center if possible.

A trauma center is a unit, typically within an emergency department, where neurosurgeons and other medical specialists treat patients with life-threatening conditions. Medical studies support the fact that treatment in trauma centers increases the likelihood of better outcomes for people with moderate to severe TBI. There are distinct levels of trauma centers, typically graded from highest (Level I) to lowest (Level IV). Trauma center designation is a process outlined and developed at the state and local level, and the process can vary from state to state.

A Level I trauma center is a regional resource that provides the highest level of medical and surgical care. There can be both adult and pediatric trauma centers. A Level I center provides full treatment from emergencies through rehabilitation. It has a full roster of specialists available 24/7 (including neurosurgery, orthopedic surgery, critical care/trauma surgery, anesthesiology, emergency physicians, radiologists, internal medicine/hospitalists, plastic surgeons, oral and maxillofacial surgeons, physical and medical rehabilitation, and various specialized therapists). Level I facilities must meet many requirements, including certain equipment that must be available; a certain number of surgeons and anesthesiologists that must be on duty; and a quality assessment program. It must also meet the minimum requirements for treating severely injured patients. Often a Level I center is affiliated with a medical school at a facility known as a teaching hospital, with ongoing research and surgical residency programs. A Level I center can serve as a referral resource for hospitals in nearby communities.

Some Level I trauma centers have dedicated neurocritical care or trauma-intensive care units (a Neuro ICU). A Neuro ICU is the highest level of care available for TBI. Not all Level I trauma centers have a Neuro ICU. If a Level I or II trauma center does not have a Neuro ICU it must at a minimum have a combined medical-surgical ICU.

A Level II trauma center can initiate care, but a Level I trauma center supports a Level II center. A Level II has some but not all the specialists that are available at a Level I institution. Level II facilities provide 24/7 service, but they do not require ongoing medical research or a surgical residency program.

A Level III trauma center has transfer agreements in place for patients requiring more comprehensive care at a Level I or II center. It does not have all the necessary specialists and usually transfers patients to a Level I or II trauma center. It provides back up resources to rural or community hospitals in case of severe injuries. Level IV centers stabilize and then transfer patients to higher level trauma centers.

Physicians may need to transfer TBI patients to receive appropriate care. Transfers take time. Time is critical in the treatment of moderate or severe TBI. However, it is important to be at a hospital equipped and prepared to give the best possible treatment. Medical research confirms that treatment in hospitals with neurosurgical support and specialized, multidisciplinary treatment (especially those with a neurointensive ICU that follows evidence-based medicine and guideline-driven protocols) is associated with better patient outcomes.^{8, 9}

Advanced Trauma Life Support in the Emergency Department

When physicians even suspect a moderate to severe brain injury and the patient is received in the emergency department, the standard of care for health care providers is to follow the Advanced Trauma Life Support (ATLS) protocol. The American College of Surgeons developed the ATLS protocol to manage trauma patients effectively and efficiently, and the goal of the protocol is to provide timely and comprehensive care.

The ATLS protocol by physicians and the medical team for managing a severe brain injury in the emergency department (ED) includes the following steps:

Primary Survey

Following the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach, the physician conducts an examination to assess and stabilize life-threatening conditions. Vital signs are monitored. In the case of a severe brain injury, airway management and breathing support are prioritized to ensure adequate oxygenation and ventilation.

Testing

A complete blood count, electrolytes, glucose, coagulation parameters, blood alcohol level, and urine toxicology are checked. Efforts to reverse any bleeding disorder (coagulopathy) should begin immediately.

Neurologic Assessment

A neurologic examination is performed to evaluate the patient’s level of consciousness, the involuntary response of the pupil of the eye to light, motor function, and signs of developing pressure on the brain known as increased intracranial pressure (ICP), such as a low heart rate, irregular respirations, and a widened pulse pressure. This assessment helps determine the severity of the brain injury.

Imaging Studies

A CT scan of the head may be ordered to assess the existence and extent of the brain injury, identify brain bleeding (intracranial hemorrhage), or detect other injuries that require timely intervention. A CT scan is the preferred type of imaging in the first few hours following a brain trauma (known as the acute phase), and it should be performed as quickly as possible in patients with moderate and severe TBI because certain damaged areas (lesions) may indicate the need for potentially lifesaving neurosurgery. A CT scan will detect skull fractures, intracranial hematomas (localized bleeding), and cerebral edema (swelling caused by fluid retention).

Intracranial Pressure Monitoring

ICP is a rise in the pressure within the brain and is potentially life-threatening. This can cause a secondary brain injury. The most common symptoms of increased ICP are headache, blurred vision, confusion, high blood pressure, shallow breathing, vomiting, changes in behavior, weakness, or problems with moving or talking. In cases of suspected severe brain injury, a pressure monitor may be placed inside the head by a neurosurgeon. The monitor device detects pressure inside the skull and sends the test results to the medical team. The physicians use this information to make treatment decisions, including whether emergency surgery is required.

Immediate Lifesaving Measures

When a patient has clinical signs of impending or ongoing high pressure within the skull (cerebral herniation), immediate lifesaving measures are required. The clinical signs of cerebral herniation include: (1) concerning results of the examination of the pupils of the eyes (pupillary asymmetry or unilateral or bilateral fixed and dilated pupils); (2) concerning patterns of involuntary body position where the patient has involuntary extension or flexion of the neck, torso, arms, and legs (decorticate or decerebrate posturing); (3) difficult breathing (respiratory depression); and (4) the “Cushing triad” of three worrisome symptoms: high blood pressure (hypertension), a slow heart rate (bradycardia), and irregular breathing (respiration).

Screening for Arterial Injury

Early screening for blunt injuries to the arteries in the neck (the carotid or vertebral arteries), which supply blood and oxygen to the brain, is required. This rare injury, known as blunt cerebrovascular injury (BCVI), can cause a damaging stroke due to blocked or reduced blood flow to the brain (ischemic stroke). Early diagnosis and treatment are critical to minimizing complications from BCVIs. The medical team should continue to closely monitor the patient for potential BCVI during the hospitalization because it can develop after the first few hours or days.

Request for Surgical Consult and Intervention

Depending on the severity of the injury in the ED, neurosurgical consultation and procedures or surgery may be recommended (discussed later in this chapter). Placement of increased intracranial pressure (ICP) monitoring devices may also be indicated.

Protective Measures

Upon arrival in the emergency department, the medical team can take steps to minimize further damage to the brain (called neuroprotective measures), including maintaining adequate oxygen flow to the brain (cerebral perfusion pressure), preventing high and low blood pressure, and controlling seizures.

Identify Other Traumas

Patients in the ED also need to be assessed for other traumas (spinal cord injury, broken bones, and other internal injuries), per the ATLS protocol.

Continuous Monitoring and Reassessment

Close monitoring of the patient’s neurologic status, vital signs, and response to interventions is required to detect changes promptly and adjust the treatment plan as needed.

Transfer to Higher Level of Care

In cases of moderate to severe brain injury requiring specialized surgical or critical care, timely transfer to a higher level of care facility equipped to provide advanced interventions may need to be arranged to optimize outcomes.^{10, 11, 12}

Neurointensive Care: A Multidisciplinary Treatment Approach

Medical research shows that when neurosurgeons and the neurocritical care support team use evidence-based medical guidelines, it leads to better outcomes. The neuro intensive care unit provides the highest level of care for severe and moderate to severe TBI.

The focus of management in moderate to severe TBI is the early recognition of neurologic worsening and the prevention of a secondary brain injury, sometimes referred to as the “talk and die” phenomenon.¹³ This is where a person suffers a head injury and initially seems to be fine, including talking and interacting normally. However, the patient has suffered underlying internal injuries or bleeding within the brain, which progresses rapidly and causes the person to die from an undiagnosed TBI. While the exact frequency of this phenomenon in moderate TBI is uncertain, some studies estimate that 30 percent of patients with moderate TBI will develop neurologic worsening.¹⁴

Accordingly, neurologic examinations are recommended to be performed every 1–2 hours for at least 24–48 hours in patients with moderate TBI. Urgent repeat imaging should be performed if there are any signs of neurological worsening. CT scan findings can show changes that evolve over time, and it is common that repeat CT exams lead to additional treatment for a sizable number of patients.¹³

The care provided by the team in the neurointensive ICU includes:

Monitoring Fluids

The normal volume of blood or fluids in the body are maintained.¹⁵

Blood Pressure

The avoidance of low blood pressure or hypotension remains a priority in the ICU.¹

Cerebral Perfusion Pressure

Continuous monitoring of oxygen flow to the brain is important to detect any decrease in oxygen in the blood (desaturation), with a goal of prompt intervention.

Ventilation

Most patients with severe TBI are sedated and mechanically ventilated (using a machine or device to support or replace breathing) during the first several days. Ventilated patients should be monitored to prevent elevations in pressure on the brain (ICP).^{16, 11}

Antiseizure Medications

Antiseizure medications are recommended to prevent and treat post-traumatic seizures in patients with TBI. Patients with TBI who develop any seizures will require ongoing antiseizure therapy. The incidence of early post-traumatic seizures (within the first week or two) may be as high as 30 percent in patients with severe TBI. In addition, research suggests that approximately 15–25 percent of patients with coma and severe head injury will have seizures identified on continuous brain monitoring (electroencephalography or EEG), but not have convulsions.^{17, 18, 19, 20}

Anticoagulant Medications and Treatment

Patients with TBI are at increased risk of a blood clot that blocks the flow of blood through the veins (venous thromboembolism or VTE). A blood clot can travel to the lungs (a pulmonary embolism) which is a life-threatening condition. To prevent this, the medical team uses pneumatic compression devices to improve circulation (an air pump is attached to inflatable sleeves, gloves, or boots to keep the blood circulating) as well as medication to decrease the risk of VTE for patients with TBI.¹¹

Management of Prolonged or Excessive Bleeding

Many TBI patients are at risk for prolonged or excessive bleeding, which is associated with an increased risk of hemorrhage, poor neurologic outcomes, and death. These patients’ ability to form blood clots (coagulate) is impaired. Accordingly, best practice is to perform a blood test for this in patients with moderate or severe TBI, and treat to correct this complication so the patient can form blood clots as soon as possible.^{21, 22, 23, 24}

Blood Sugar (Glucose) Management

Avoidance of both hypoglycemia and hyperglycemia (blood sugar levels that are too low or too high) is appropriate for patients with moderate or severe TBI. Both are associated with worsened outcomes in severe TBI.²⁵

Temperature Management

Fever is associated with worse outcomes in TBI and may cause a secondary brain injury. Fever can also worsen control of pressure in the brain because of the stresses caused by injury (an increase in metabolic demand, blood flow, and blood volume). The medical team will attempt to avoid fever by using medications or cooling devices. Shivering may also increase metabolic demand and worsen brain tissue oxygenation and may require management and treatment.^{4, 26}

Nutritional Support

Guidelines recommend that basic nutritional goals be achieved no later than five-to-seven days from injury and that tube feeding be considered to decrease the rate of ventilator-associated pneumonia.¹

Intracranial Pressure Management and Monitoring

Elevated ICP is associated with increased mortality and worse outcomes. Specific measures to prevent increased ICP require that patient assessment should be performed every one-to-two hours in the first few days after moderate or severe TBI. Clinical signs of impending brain herniation require immediate response. Current BTF guidelines recommend that the medical team use the information from ICP monitoring to guide the management of patients with severe TBI.^{27, 12, 1}

Sedation and Analgesia

The Society of Critical Care Medicine recommends analgesic and pain medications to decrease duration of mechanical ventilation and ICU length of stay. Patients with significant ICP elevation are managed with sedatives and pain medication, which may lower ICP.^{28, 29}

Regular Blood Tests

Blood tests should be performed regularly for safety, often at four-to-six-hour intervals, to detect and correct other complications, such as excessive elevation of chloride levels (hyperchloremia), low or high levels of potassium in the blood (hypokalemia or hyperkalemia) and sodium in the blood (hypernatremia), which are associated with increased mortality in severe TBI.³⁰

Decompressive Craniectomy

A decompressive craniectomy is a surgery. It is lifesaving and is recommended based on clinical findings on examination or CT findings that indicate life-threatening pressure within the skull (intracranial hypertension). In a decompressive craniectomy, a substantial portion of the skull (the cranial vault) is removed to allow brain tissue to swell without being squeezed within the confines of the skull.^{31, 32} While many patients who require decompressive craniectomy as a lifesaving procedure will suffer severe disability, some will attain a “good quality of life.”³³

Medically Induced Coma

Another option for patients with ICP elevation that is not responding to other measures is a medically induced coma using certain sedative medications (barbiturates). While effective for the control of ICP, the use of a medically induced coma has not been shown to improve outcomes following TBI.³⁴

The medical specialists that provide care for the TBI patient in the neurointensive ICU include:

Neurosurgeon

A surgeon who specializes in the surgical management of brain injuries.

Neurointensivist

A neurointensivist is a physician responsible for coordinating and overseeing the care of TBI patients in a neurointensive ICU and is responsible for managing concerns about ICP, optimizing the flow of oxygen carrying blood to the brain tissue (cerebral perfusion), and ensuring the stability of TBI patients.

Critical Care Nurses (RNs, Advanced Practice Nurses, and Nurse Practitioners)

These nurses provide support by monitoring vital signs, administering medications, and implementing care plans under the direction of the medical team. Critical care nurses are trained to follow neurocritical care guidelines and protocols, which are set by the hospital.

Respiratory Therapists

Respiratory therapists collaborate closely with the medical team to manage the mechanical ventilation and oxygenation of TBI patients with compromised respiratory function to optimize respiratory capacity, provide airway management, and deliver respiratory care.

Physical, Occupational, and Speech Language Therapists

Physical, occupational, and speech language therapists collaborate to provide rehabilitation services to TBI patients in the neurointensive ICU, focusing on restoring mobility, strength, coordination, swallowing and airway management and assessment.

Neurologists, Neuropsychologists, Neuropsychiatrists, Rehabilitation Specialists and Social Workers

These providers address psychological, cognitive, and emotional needs during the recovery process. They may offer counseling, cognitive assessments, coping strategies, and resources to enhance emotional well-being and adjustment to the challenges of living with a brain injury.

Neurosurgical Treatments and Procedures

Neurosurgeons are brain surgeons with advanced training. They perform surgeries on conditions affecting the brain (as well as the spinal cord and peripheral nerves). Neurosurgeons collaborate with other health care providers in the ICU and the entire medical team caring for the patient. They are specialists that recommend whether to perform brain surgery, and the type of surgery that is needed.

A neurosurgeon’s role in the treatment of TBI includes: assessing and managing acute intracranial hemorrhages, hematomas, contusions, and other traumatic brain injuries requiring surgical intervention; performing procedures to decompress the brain, removing blood clots or areas of damaged brain tissue, repairing skull fractures, controlling bleeding, attempting to alleviate ICP; and collaborating with the medical team to develop comprehensive treatment plans, and monitor and treat patient neurological condition.

When neurosurgeons recommend surgery they consider factors such as the severity of the injury, the specific part of the brain injured, and the patient’s age and health. In the moderate to severe TBI cases, the neurosurgeon may recommend surgical treatment to help a patient survive the primary brain damage or prevent secondary injuries from developing.

Emergency neurosurgical care for TBI focuses on keeping the patient alive and stable by making sure their brain gets enough oxygen, controlling blood and brain pressure, and preventing further injury to the head or neck.

The procedures that neurosurgeons perform include:

Craniotomy

Surgically opening the skull to access the brain, remove hematomas, repair injuries, or relieve ICP.

Craniectomy

Temporarily removing a portion of the skull to accommodate brain swelling, reduce pressure, and prevent herniation.

Burr Hole Surgery

Creating small openings in the skull to drain hematomas, relieve pressure, or insert monitoring devices.

Skull Fracture Repair

Reconstructing and stabilizing skull fractures to protect the brain and prevent infection.

Shunt Placement

Inserting a ventricular shunt (a device used to relieve excessive pressure on the brain) to manage fluid accumulation in the brain (hydrocephalus) and regulate cerebrospinal fluid flow.

Intracranial Pressure Monitoring

Placing devices to monitor and manage ICP fluctuations postoperatively.

Depending on the type of surgery needed and the level of urgency, the patient and their family need to be prepared for all the following: undergoing a physical exam, cognitive and breathing assessments, blood tests (including angiography/arteriography), imaging tests (including an x-ray, MRI, CT scan, PET scan); avoiding eating and drinking (if applicable); stopping certain medications on the recommendation of the medical team; beginning prophylactic medications like antibiotics to ward off infection, anticonvulsants to protect against seizures, and diuretics to reduce fluid buildup; and, having their hair shaved or incision site cleaned. This pre-surgical preparation process ensures the patient is as stable and ready as possible before any procedure.

Immediately after surgery, the patient and their family can expect the following: transfer to an ICU where their vital signs, bleeding, swelling, and pain can be closely monitored and managed; remaining hospitalized for several days or weeks while their condition continues to be monitored; resting while keeping their head upright instead of lying flat; receiving instructions for at-home care when ready for discharge; and, attending follow-up appointments to ensure they are healing as expected.