University
of Kentucky / UK HealthCare
Departments of Surgery, Emergency Medicine, Anesthesiology, and Neurosurgery
Management Protocol
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Purpose: Provide practice guidelines for evaluation,
consultation, and management of Traumatic Brain Injury
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Background
1.
There is limited background for standardized guidelines
on assessment and management of immediate Traumatic Brain Injury (TBI).
2.
TBI requires a multidisciplinary team for appropriate
utilization of resources, and consultation of services.
Recent studies have developed protocols for safe and
appropriate diagnosis and management of TBI.
The Brain Injury Guidelines (BIG) protocol has been assessed in large
volume studies.1 The following Table classifies the diagnosis
and treatment of different types of TBI based on BIG categories. In a study of 1232 patients with abnormal
head CT (among a cohort of 3803 TBI patients), BIG 1 assessement and treatment
resulted in no clinical/radiographic worsening with no intervention required. BIG 2 patients had radiographic worsening in
2.6% of patients. All neurosurgical
interventions were in BIG 3 patients.
Table 1. BIG Protocol
Patient Selection
The BIG protocol will be applied to any adult (16 years or
older) with TBI ranging from mild (concussion) to severe.
Protocol
Patients will be assessed
and managed per the protocol outlined in Table 1.
Additional clinical
management issues are clarified below:
1. Neurosurgery will see patients with abnormal head CT and GCS < 8 within 30 minutes of notification.
2. Seizure prophylaxis (Keppra or Dilantin) is recommended
for 7 days for any patient with intraparenchymal hemorrhage (intracranial or
intraventricular hemorrhage) of any size or BIG 3. However, if the patient has a witnessed
seizure please consult Neurosurgery and Neurology.
3.
It is not clinically indicated to hold NSAIDs if they
are recommended for other pathology in the patient.
4.
DVT prophylaxis is recommended starting at 24 hours
after admission for BIG 1, and 48 hours after admission for BIG 2. For BIG 3, please request clarification from Neurosurgery
service.
5.
Defer to Neurosurgery service for questions regarding
holding/restarting of anticoagulation medications.
6.
All BIG classifications should followup in Trauma
(Blue) clinic after discharge. Patients
who have undergone neurosurgical intervention should also followup with
Neurosurgery. Patients discharged on
continuing anti-epileptic medications (beyond 7 days) should followup with
Neurology.
7. Post-TBI symptoms that continue beyond 90 days or clinically worsen after discharge should result in referral to Cardinal Hill Rehabilitation Hospital TBI Clinic.
Communication and Adherence
These guidelines are not intended as a directive or to
present a definitive statement of the applicable standard of patient care. They
are offered as an approach for quality assurance and risk management and are
subject to (1) revision as warranted by the continuing evaluation of technology
and practice; (2) the overall individual professional discretion and judgment
of the treating provider in a given patient circumstance; and (3) the patient’s
willingness to follow the recommended treatment.
Any questions about a patient’s candidacy for
management under this protocol should result in a multidisciplinary
communication, most notably between the Trauma (Blue) Service and Neurosurgery
Service.
Concerns about the protocol and its application should
be addressed to Andrew Bernard at andrew.bernard@uky.edu.
REFERENCES
1. Joseph B, Friese RS, Sadoun M, Aziz H,
Kulvatunyou N, Pandit V, et al. The big (brain injury guidelines) project:
Defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg.
2014;76:965-969
Glasgow Coma Score (Updated 2014)
Eye Opening
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Verbal
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Motor
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6
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Obeys Commands
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5
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Oriented
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Localizes
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4
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Spontaneous
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Confused
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Normal Flexion
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3
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To Sound
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Words
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Abnormal Flexion
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2
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To Pressure
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Sounds
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Extension
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1
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None
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None
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None
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Key points:
Give EMV in individual scores, not summative GCS (note
many other centers report EVM, not EMV).
Give a number for verbal if talking around their
ETT/Trach.
Assessment for painful
stimuli: axillary pectoral muscle pinch.
Assessment for spinal cord reflex: nailbed pressure
Admit Location
Multi-system severely injured
patients are generally admitted to 7-100 and 7-200.
Isolated or primary severe TBI
patients are generally admitted to 6-200.
Imaging
See Trauma Imaging and Concussion Guidelines:
