View
450
Download
5
Embed Size (px)
Citation preview
Traumatic Brain InjuryRobert Lieberson, MD, FACS
Brain, Spine, and Peripheral Nerve Surgery
Your Learning ObjectivesAt the conclusion of this session, you will be able to:1. understand the demographics of TBI; 2. discuss the approach to the TBI patient; 3. describe the examination and the evaluation
of the TBI patient;4. recognize many of the common injuries;5. be familiar with some of the medical
treatment options;6. be aware of some of the surgical options; and,7. appreciate the prognosis in TBI.
My Teaching ObjectivesProvide a framework for understanding:1. in an emergency start with ABCs or ABCDEs;2. remember the GCS as top down and small
number of options to large;3. think about the rest of your examination from
the top down;4. think about brain injuries from the outside in;
and,5. think about TBI treatment in terms of re-
establishing “normal.”
“Doctors are men who prescribe
medicines of which they know little, to
cure diseases of which they know less,
in human beings of whom they know
nothing.”
– Francois Marie Arouet Voltaire
(1694-1778)
1. Demographics of TBI 2010
> 50 K Deaths
> 280,000 Hospitalization
s~ 2,500,000
Emergency Room Visits
? Alternate care or no care
789,925
Men
574,870
Women
At least 3 to 5 million TBIs
per year in the US
By cause All ages Assault
11% Struck By/
Against15%
Unknown/Other19%Motor Vehicle-
Traffic14%
Falls41%
Frequency by age
0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 +0
200
400
600
800
1000
1200
1400
Per 1
00,0
00
2. Approach to the TBI Patient
Schematic behavior ("on autopilot“) versus attentional behavior (problem-solving)
Failures of schematic behavior are “slips” (lapses in concentration, distractions, or fatigue).
Failures of attentional behavior are “mistakes” (lack of training or experience).
In health care, most errors are caused by “slips.”
Checklists reduce the risk of “slips.”
2. Approach to the TBI Patient
Advanced Trauma Life Support (ACS)
www.cdc.gov/TraumaticBrainInjury/ Guidelines for the Management of
Severe Traumatic Brain Injury, 3rd Edition, 2007
Guidelines for the Surgical Management of Traumatic Brain Injury, 2006
Guidelines for Management and Prognosis of Severe Traumatic Brain Injury, 2000
Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents, 2nd Edition, 2012
Ghajar J, Hariri RJ, Narayan RK, Iacono LA, Firlik K, Patterson RH.
Survey of critical care management of comatose, head-injured patients in the United States.
Critical Care Med. 1995 Mar;23(3):560-7.
Adherence to the TBI guidelines improves outcomes, but in a survey of ICUs in 45 states:
Only 28% of neurosurgeons routinely measure ICP
83% still use hyperventilation and osmotic diuretics
29% still maintain PaCO2 < 25 mm Hg 44% still use corticosteroids
Start with Advanced Trauma Life Support Primary Survey
ABCDEs Secondary Survey
GCS from the top down (EVM) General examination from the top down Neuro examination from the top down
Tertiary Survey PMH, FH, SH, Meds, Allergies, ROS
If the patient deteriorates, return to the primary survey and start over
3. Evaluation of the TBI Patient
ATLS primary survey
ABCDE (different than the ABCs of CPR) Airway (remember the c-spine precautions) Breathing (exclude pneumothorax,
tamponade, etc) Circulation (and also control hemorrhage) Disability/neurological (AVPU [alert, verbal,
painful, unresponsive], pupils and spinal cord (GCS goes with secondary survey)
Environmental (remove clothes, correct/prevent hypothermia)
ATLS Secondary Survey
Complete history Top down examination (including GCS) X-rays and lab
Focused abdominal sonogram for trauma (FAST exam)
Evaluates pericardium, right and left upper abdomen and pelvic region for blood
CBC, BMP, coags, type and screen, tox, ABG, pregnancy
Non-contrast CTs of C-spine, chest, abdomen, and pelvis
Maintain PaO2 > 60 mm Hg and SBP ≥ 65 mm Hg
ATLS Tertiary Survey
Careful and complete examination, serial assessments, rate of delayed diagnosis can be 10%
If patient deteriorates, return and repeat the primary survey
History Events surrounding the
accident Seatbelt, helmet, position in
motor vehicle, direction of impact, speed, damage to windshield or steering wheel
Assess for EtOH or illicit drugs Drugs may confound the
examination Was there a seizure at the
time of the accident
HistoryMechanism of Injury
Rotational most likely to cause shearing
Lateral and AP cause coup and contra-coupand subdurals
Local injury to the temporal bone causes epidurals
Examination—General Head
Scalp lacerations May be associated with significant blood loss
Depressed skull fracture (convexity fractures) Most skull fractures non-displaced
CSF rhinorrhea or otorrhea, raccoon eyes, Battle’s sign (basilar skull fractures)
Significant head injuries can occur without external stigmata
Spine Step-off Tenderness
Passive rewarming Hypothermia may confound the neurological
examination
Examination—Glasgow Coma Scale
GCS 13-15 is “mild”
GCS 9-12 is “moderate”
GCS 3-8 is “severe” and equates to coma
Eyes
Verbal
Motor
Top Down4
56
Examination—Glasgow Coma ScaleTop down (EVM); fewest categories to most.
Eyes
Verbal
Motor
Top Down4
56
1 None
2 Decerebrate
3 Decorticate
4 Withdraws
5 Localizes
6 Normal
Motor
1 None
2 Sounds
3 Word Salad
4 Disoriented
5 Normal
Verbal
1 None
2 To Pain
3 To Voice
4 Normal
Eyes
Neurological Examination A complete neurological examination on
every patient (organized from top down) Mental status Cranial Nerves (including pupils) Motor (rate power from 0/5 to 5/5) Sensory (light touch and pin prick) Reflexes (0, 1, 2, 3, 4) Coordination/Gait
Post Traumatic AmnesiaRetrograde versus antegrade
Fixed and Dialated Pupils No patient with
bilateral fixed and dilated pupils for more than 90 minutes had a favorable outcome.
Many surgeons will consider surgery futile if 3 to 6 hours have elapsed.
Papiledema
Normal Disc
Late Papiledema (grade
IV)
Early Papiledema (grade II)
Indications for CT
Mild TBI (GCS ≥ 13) New Orleans Criteria
No CT if GCS 15, + LOC, no neuro deficit, age > 3 years CT if headache, vomiting, seizure, intoxication, short term memory
deficit, age > 60, injury above the clavicle Canadian CT Head rule
No CT if GCS 13-15, + LOC, no neuro deficit, no seizure, no anticoagulation, age > 16 years
CT if: High risk—GCS < 15 after 2 hours, suspected convexity or basilar skull
fracture, vomiting ≥ 2 times, or age ≥ 65; or, Medium risk—retrograde amnesia > 30 minutes, severe mechanism
(pedestrian vs. car, ejected from car, or fall from > 1 m or five stairs)
Indications for CT
Moderate TBI (GCS 9-12) or Severe TBI (GCS ≤ 8) All get a head CT
CT is positive in 93% of patients with a severe TBI A negative CT does not guarantee a “favorable”
prognosis Obliteration of basal cisterns associated with
“unfavorable” outcomes in 97% of cases
4. Recognize Common Injuries
Layers from outside to inside
Scalp Contusion
Caput succedaneum
Subgaleal hematoma
Subperiosteal hematoma or cephalohematoma
Subgaleal versus subperiosteal hematoma
Epidural hematoma
Epidural hematoma
Subdural hematoma
Subdural hematoma
Subarachnoid Hemorrhage
Cerebral Contusion
Cerebral Contusion
Axonal Shearing Injuries
Intraventricular Hemorrhage
Through and Through Gunshot Wound
Marshall Classification of CT findingsDiffuse injury I—No visible pathology on CTDiffuse injury II—Cisterns present, midline
shift < 5 mm, no high-density lesion > 2.5 cm
Diffuse injury III—Cisterns compressed or absent, no high-density lesion > 2.5 cm
Diffuse injury IV—Midline shift > 5 mm, no high-density lesion > 2.5 cm
Evacuated mass—Any lesion surgically evacuated
Non-evacuated mass—High-density lesion > 2.5 cm but not surgically evacuated
Traumatic dissections
Traumatic dissections
5. Medical Treatment Options Primary Injury
Occurs at the moment of trauma Contusion, damage to blood vessels, axonal shearing, blood brain barrier
changes, fractures, and meningeal injury Secondary Injury
Begins in the hospital (causes significant disability, preventable) Ischemia and cerebral hypoxia (due to hypotension and impaired
autoregulation) Cerebral edema (raised intracranial pressure, brain herniation) Metabolic changes such as hypercapnia and acidosis Infection (meningitis, brain abscess) Release of neurotransmitters (excitotoxicity) Viscous Cycles (edema causes more ischemia which causes more edema) Systemic complications (pneumonia, DVT)
TBI Guidelines 3rd Edition, 2007
Three classes of evidence Class I: Relevant screening test; credible reference standard;
reference standard independent of screening test; reliability of test assessed; few indeterminate results; large number of patients.
Class II: Relevant screening test; reasonable although not best standard; standard independent of screening test; moderate number of patients.
Class III: Has fatal flaws; inappropriate reference standard; screening tests improperly administered; small number of patients.
Three levels of recommendation (based on class of evidence, highest level with at least one recommendation given)
15 categories, only 14 stated “level of evidence” Level I: 1/14 (steroid use) Level II: 10/14 (BP, Mannatol, Abx, ICP monitoring, ICP
threshold, CPP, anesthetics, nutrition, Sz meds, hyperventilation)
Level III: 3/14 (hypothermia, DVT, brain O2 monitoring)
I. Blood Pressure and Oxygenation B. Level II—Hypotension (SBP < 90 mmHg) should be
avoided. C. Level III--Hypoxia (PaO2 < 60 mmHg or O2 saturation <
90%) should be avoided
Single most important intervention is maintaining SBP and CBF CBF should be between 50 and 70 Under 50, risk of ischemia Over 70, risk of ARDS
TBI Guidelines (I)
TBI Guidelines (II)
II. Hyperosmolar Therapy B. Level II--Mannitol is effective to treat ICP. Doses of 0.25 to 1
g/kg. C. Level III--Restrict mannitol use prior to ICP monitoring to
patients with signs of herniation or progressive neurological deterioration.
Albumen, SAFE trial of 7000 patients, ↑ ICP, No Benefit Hypertonic Saline
↓ cerebral edema, ↑ flow through small vessels, ↑ MAP Avoids the diuresis, ↓ BP seen, and renal issues with Mannitol
Mannitol Rapid decrease ICP in emergencies Renal damage if Osm over 320
TBI Guidelines (II)
II. Hyperosmolar Therapy
TBI Guidelines (III)
III. Prophylactic Hypothermia C. Level—Better outcomes with temperatures of 32–33°C
for > 48 hours. Difficult to do.
First studies by Temple Fay (1895-1963, Temple U) ↓ metabolic rate, ↓ apoptosis ↓ neuroexcitatory damage, ↓
inflammatory damage, ↓ free radicals ↓ Cerebral Blood Flow, ↓ ICP
But ↓ Platelet Function Rewarming Problems (↑ K+, ↓ glucose)
TBI Guidelines (III)
Prophylactic Hypothermia Tylenol, fans, ice bags, etc—not
adequate Intravenous heat exchangers may be
effective Shivering can be controlled with
warming of the hands Induced Normothermia
Preventing fever spikes may be as advantageous as hypothermia
Pending studies Eurotherm 3235 (600 patients) - UK POLAR-RCT (500 patients) – Australia
and NZ
TBI Guidelines (IV and V)
IV. Infection Prophylaxis B. Level II--Periprocedural antibiotics for intubation should be administered. Early tracheostomy
should be performed to reduce ventilator days. C. Level III--Routine ventricular catheter exchange or prophylactic antibiotic use is not
recommended. V. Deep Vein Thrombosis Prophylaxis
C. Level III--Compression stockings are recommended. Low molecular weight heparin (LMWH) or low dose unfractionated heparin should be used, however, there is an increased risk of hemorrhage. There is no clear preferred agent.
There are NO guidelines for Lovenox or similar in patients with TBI. Giving Lovenox BEFORE a craniotomy is NOT safe. In patients with a “bleed,” starting Lovenox 24 to 48 hours AFTER the CT has stabilized and there is
no more bleeding is probably safe. In post-op craniotomy patients, starting Lovenox 24 or 48 hours after surgery, or when the drains
stop producing fresh blood, is probably safe.
TBI Guidelines (VI through VIII)
VI. Indications for Intracranial Pressure Monitoring B. Level II--Monitor Intracranial pressure (ICP) in all salvageable patients
with a severe TBI (GCS 3–8) and an abnormal CT scan. C. Level III--ICP monitoring is indicated in patients with severe TBI with a
normal CT scan if two or more of the following: age over 40 years, unilateral or bilateral motor posturing, or SBP < 90 mm Hg.
VII. Intracranial Pressure Monitoring Technology A ventricular catheter and an external strain gauge is the most accurate,
low-cost, and reliable method. It can be recalibrated. Strain gauge devices provide similar benefits, but cost more and cannot be recalibrated.
VIII. Intracranial Pressure Thresholds B. Level II—Treat ICPs above 20 mm Hg. C. Level III—Use a combination of ICP values, clinical findings, and CT
findings to guide treatment (common sense).
TBI Guidelines (VI through VIII)(Monro-Kellie doctrine)
Alexander Monro (1733-1817), Scottish a famous-anatomist, surgeon, and lecturer
George Kellie (1720-1779), Scottish anatomist and surgeon who studied under Monro
TBI Guidelines (VI through VIII)
Brain
Arterial Blood
Venous Blood
CSF
ECF
140 to 270 cc of CSF (25 in the ventricles)
1050 to 1150 cc of
brain
200 cc of ECF
100 cc of venous blood
50 cc of arterial blood
Mannitol
Ventricular
DrainageHyper-
ventilation
TBI Guidelines (VI through VIII)
Brain
Arterial BloodVenous Blood
CSF
ECF
Brain
Arterial BloodVenous Blood
CSF
ECFSubdural
Hematoma
TBI Guidelines (VI through VIII)
Brain
Arterial BloodVenous Blood
CSF
ECF
Subdural Hematoma
TBI Guidelines (VI through VIII)
Brain
Arterial BloodVenous Blood
CSF
ECFSubdural
Hematoma
TBI Guidelines (VI through VIII)
TBI Guidelines (IX and X)
CPP = MAP - ICPCerebral Perfusion Pressure is MAP minus
ICP. If MAP is 90 and ICP is 20, CPP is 70.CPP should be 50 to 70 mmHg.CPP over 70—ARDS more likely.CPP less than 50—No brain perfusion!
TBI Guidelines (VI through VIII)
↓ CBF
Failure of Oxydative
Metabolism
Na2+/K+ Pump Failure
↑ Cellular Edema
↑ ICP
Secondary InjuryVicious Cycle
TBI Guidelines (VI through VIII)ICP Monitoring Technology
A ventricular catheter and external strain gauge are the most accurate, reliable, and method of monitoring.
Ventriculostomies allow CSF Drainage.
Convenient, fast, accurate.
Cannot be recalibrated after insertion, and are expensive ($6,000 to $10,000).
TBI Guidelines (VI through VIII)ICP Monitoring Technology
TBI Guidelines (VI through VIII)ICP Monitoring Technology
Objectives of ICP Monitoring
Maintain cerebral perfusion (and therefore oxygenation)
Remove CSF (if possible)Avoid secondary injury
TBI Guidelines (VI through VIII)Herniation
1.Subfalcine2.Transtentorial3.Uncal4.Transforaminal5.Upward (Posterior
Fossa)6.Through a cranial
defect
TBI Guidelines (VI through VIII)Basal Cisterns
TBI Guidelines (VI through VIII)Herniation
TBI Guidelines (IX and X)
IX. Cerebral Perfusion Thresholds B. Level II—Ovrly aggressive attempts to keep CPP > 70 mm Hg with fluids
and pressors should be avoided because of the risk of adult respiratory distress syndrome (ARDS).
C. Level III--CPP of < 50 mm Hg should be avoided. The CPP value to target lies within the range of 50–70 mm Hg.
X. Brain Oxygen Monitoring and Thresholds C. Level III—Maintain jugular venous saturation > 50% or brain tissue
oxygen tension >15 mm Hg. The technology exists but is limited.
TBI Guidelines (XI to XV)
XI. Anesthetics, Analgesics, and Sedatives B. Level II--Prophylactic barbiturates not recommended. Barbiturates for ICP
refractory to all other treatment helpful but cause significant morbidity. XII. Nutrition
B. Level II--Full caloric replacement by day 7. XIII. Anti-seizure Prophylaxis
B. Level II—Prophylactic, long-term anti-epileptics not recommended. Anticonvulsants decrease early seizures but early seizures not associated with worse outcomes.
XIV. Hyperventilation B. Level II--Prophylactic hyperventilation (PaCO2 < 25 mm Hg) is dangerous. C. Level III--Temporizing measure only. Most harmful early when CBF most reduced.
XV. Steroids A. Level I—Steroids are not recommended—cause increased mortality. This is the only level II recommendation.
TBI Guidelines Summary
Intubate if: Poor airway protection
or GCS ≤ 8 Extubate early
PaO2 > 60 mmHG or O2 Sat > 90%
PaCO2 = 35 to 40 mm HG
Keep SBP > 90 and CPP 50-70 A single episode of
hypotension doubles mortality
Avoid hypotonic solutions (LR or ½ NSS)
Avoid hyperglycemia
Mannitol Signs of herniation
or progressive deterioration not due to extracranial causes
Dose 0.25 to 1 g/Kg Avoid before ICP
monitoring Avoid if hypotensive
Hypothermia QUESTIONABLE. Steroids NOT helpful. Anticonvulsants NOT for
prophylaxis. Antibiotics NOT for prophylaxis. Hyperventilation NOT advised. Full caloric replacement early. DVT prophylaxis (SCDs, +/-
anticoagulation). Avoid high dose Propofol. Barbiturates only in desperation.
TBI Guidelines Summary
TBI Guidelines Summary Monitor ICP in all “severe” head injury patients (GCS ≤ 8) with an abnormal CT.
Monitor ICP in all “severe” head injury and a normal CT if two or more of the following:Age ≥ 40 years;Systolic blood pressure ≤ 90 mm Hg; and,Unilateral or bilateral posturing.
Not in the TBI GuidelinesDecompressive Craniectomy
Has waxed and waned in popularity over the last 30 years
Indications now not entirely clear.May be helpful for hemispheric or MCA strokes.For TBI, probably to be done in desperation only.A very large craniectomy is required.May occasionally cause worse problems (strangulation of
the brain under the new defect).May convert deaths into vegetative survivors.
Not in the TBI GuidelinesTransfusion thresholds
Historical: 30% or 10 g/dLReassessed 1980s—infection risk and cost AABB Guidelines (2012)
Hgb <6 g/dL – Transfusion recommended Hgb 6 to 7 g/dL – Transfusion generally indicated Hgb 7 to 8 g/dL – Transfusion should be considered in postoperative
surgical patients Hgb 8 to 10 g/dL – Transfusion generally not indicated, but should be
considered for: symptomatic anemia; ongoing bleeding; acute coronary syndrome (cardiac surgery literature supports 30%)
Transfusion thresholds for TBI undefined Some including Carlson, 2006, suggest that the same guidelines apply Many neurosurgeons believe that because of the brain’s higher O2
consumption, a hematocrit near 30% reduces risk and improves outcome.
6. Surgical Management of TBI 2006 Addresses Four Classes of
Lesion Epidural Hematomas Subdural Hematomas Contusions (Parenchymal
Lesions) Posterior Fossa Mass Lesions
Surgical Management of Epidurals
Indications for Surgery An epidural over 30 cm3 should be removed regardless of the GCS score. An epidural less than 30 cm3 and with less than a 15-mm thickness and
with less than a 5-mm midline shift and with a GCS score greater than 8 without focal deficit can be managed nonoperatively but need serial scans and close follow-up.
Timing Patients with an acute epidural in coma with anisocoria need surgery
immediately. Methods
Craniotomy. Exceptions
Venous epidurals.
How do you determine volume on CT
Kothari, et al, 1996. Find largest diameter (call it A) Find diameter at 90 degrees to A (call it B) Count the CT slices where the clot is seen and
multiply by slice thickness to find the depth (call that C)
Lesion volume = In a 30 cc lesion, the average value of A, B, and C
is about 4 cm or 1½ inches
How do you measure shift on CT?
15 mm
How do you remove skull
Surgical Management of Epidurals
Surgical Management of Epidurals
Surgical Management of Epidurals
Surgical Management of Epidurals
Surgical Management of Subdurals
Indications for Surgery An acute subdural 10 mm thick or a midline shift over 5 mm should
be removed regardless of the GCS. • All patients with an acute SDH in coma (GCS score less than 9)
should undergo intracranial pressure (ICP) monitoring. • A comatose patient with a SDH < 10-mm thick and a shift < 5 mm
needs surgery if the GCS decreased between injury and admission or if pupillary changes or if the ICP exceeds 20 mmHg.
Timing Patients with an acute subdural in coma with anisocoria need surgery
immediately. Methods
Craniotomy
Surgery—subdural hematoma
Surgery—subdural hematoma
Surgery—subdural hematoma
Surgery—subdural hematoma
Surgery—subdural hematoma
Surgery—subdural hematoma
Surgical Management of Contusions
Indications Patients with parenchymal lesions
and neurological deterioration, medically refractory ↑ ICP, or mass effect on CT needs surgery.
Patients with GCS of 6 to 8, with frontal or temporal contusions greater than 20 cm3 in volume with shift > 5 mm or loss of basal cisterns, and patients with lesions over 50 cm3 need surgery.
Patients with mass lesions who do not show evidence of neurological compromise, have low ICP, and no signs of mass effect on CT may be observed with serial CTs.
Surgical Management of Contusions
Timing and Methods Bifrontal decompressive
craniectomy, within 48 hours of injury, should be considered for diffuse cerebral edema.
Decompressive procedures (subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy) are options for patients with ↑ ICP.
Surgical Management of Posterior Fossa Lesions
Indications Patients with mass effect on CT or with neurological dysfunction or
deterioration need surgery. Mass effect is distortion of the fourth ventricle, compression of the basal cisterns, or hydrocephalus.
Patients with lesions but no mass effect on CT or neurological deficit may be observed and imaged serially.
Timing Patients can deteriorate rapidly. Surgery should be done
immediately. Methods
Suboccipital craniectomy is used to evacuate posterior fossa lesions.
Surgery—posterior fossa lesions
Surgery—depressed skull fracture Indications
In driven fragments increase seizure risk Open fractures increase infection risk
Surgery—depressed skull fracture
Surgery—depressed skull fracture
Surgery—decompressive craniectomy
7. Prognosis (2000)
Relatively few features have been found to contain most of the prognostic information. Patient Age Severity of Injury
Difficult to quantify Intracranial pressure
Not always measured Computed tomography (CT)
Prognosis (2000)
Glasgow Coma Score (severity of injury) Works well for very low and very high
initial GCS scores. Age
Younger patients do better and those over 60 worse
Pupillary reactivity (severity of injury and ICP)
Hypotension Strongly predicts a poor outcome The only factor that can be changed
CT abnormalities predict a poor outcome (severity of injury and ICP)
Glasgow Outcome Score (GOS)
2 MD Moderate disability (disabled but independant)—travel by public transportation, can work in sheltered setting (exceeds mere ability to perform “ADLs”).
3 SD Severe disability (conscious but disabled)—dependent for daily support (may be institutionalized, but this is not a criteria).
4 PVS Persistent vegetative state—unresponsive and speechless; after 2-3 weeks may open eyes and have sleep/wake cycles.
5 D Death—most deaths from primary head injury occur within 48 hours.
1—Death (D)
2—Vegitative State (VS)
3—Lower Severe
Disability (SD-)
4—Upper Severe
Disability (SD+)
5—Lower Moderate
Disability (MD-)
6—Upper Moderate
Disability (MD+)
7—Lower Good Recovery (GR-)
8—Upper Good Recovery
(GR+)
Glasgow Outcome Score-Extended (GOS-E) Reversed the numbers Added “lower” and “upper” to the three intermediate
categories
75% “mild” Thinking memory and reasoning Sensation vision, smell, and taste Language communication, understanding Emotion anxiety, depression, personality, inappropriate behavior
25% “Moderate” or “Severe” Seizures Parkinson’s Disease Dementia Paralysis PVS
Spectrum of Effects of TBI (numerous independent variables)
More PearlsMortality from epidural
hematoma about 10%.Mortality from subdural
hematoma 40 to 60%.Hypoxia increases mortality.Hypotension doubles mortality.Recovery may continue for a year
or more.
Organize With a TBI start with ABCDEs. Remember the GCS as top down and
small number of options to large. Think about the rest of your examination
from the top down. Think about brain injuries from the
outside in. Think about TBI treatment in terms of
keeping all the numbers normal.
And now a word from our sponsor!