Transfer of the Head Injured Patient

Barbara Stanley FRCA

Why It Matters• 1.4 million head injuries a

year:– 50,000 die.– 90,000 permanently disabled.

• Primarily affects young adults.

• Hypotension alone increases mortality from 27% to 60%.

• Hypoxia, in addition to hypotension, is associated with a mortality of 75%.

• Poor outcome associated with:– >60 yrs old– Bilateral fixed dilated pupils– Single BP reading <90mmHg

systolic doubles mortality– tSAH doubles mortality– Midline shift

• Direct worsening of outcome if transfer not executed correctly – physiology of raised ICP

Intracranial Physiology:- Monroe-Kellie Doctrine

Why Herniation Occurs

Why Hypoxia/Hypotension and Hypercarbia Are Detrimental

• Autoregulation – the ability of the cerebral vasculature to maintain its supply over a range of perfusion pressures

• Raised PaCO2 causes cerebral vasodilation• Hypoxia SPO2 <90% causes vasodilatation• Prevention of secondary cerebral injury

relies on prevention of cerebral vasodilation which increases intracranial volume and thus pressure

• Protection of vulnerable “penumbra”

CPP= MAP-(ICP+CVP)

The Polytrauma Patient with a head injury

• 25 yr old male• Front seat passenger RTC – driver dead• Extrication of 1 hour• GCS 14 at scene now 11• Obvious open femoral fractures and bruising

to abdomen• Priorities of Management?

Who Needs Transferring?

• Discuss and/ or Transfer:– New intracranial lesions on CT– Persistent coma GCS <8– Deteriorating GCS– Progressive focal neurological signs – Severe TBI whether lesion operable or not– Penetrating TBI – CSF Leak

Aims of Transfer• Anticipate and prevent occurrence of

problems that will adversely affect patient outcome eg:– Hypotension– Hypoxia/hypercarbia– Aspiration– Acute rises in ICP– Equipment failure/running out of drugs or

oxygen

• The overriding aim is to control the intracranial hypertension and maintain CPP

Before Transfer:

• Airway – patients with a GCS 8 or less must be intubated– Consider intubation if GCS drops 2 points or more

regardless baseline• Breathing – Pneumothoraces etc must be drained prior to

transfer• Circulation – must be stable before transfer– Hypotension in head injured patient = bleeding = go to

theatre• Disability – Neuro exam/ blood results/ ABG result/

assessment of all other major injuries

Logistics

• Document name of surgeon/consultant • Contact details• Destination• Means of contacting base and destination hospital• “Adequately trained assistant”• Return journey• All relevant notes/results• Inform relatives of transfer and details

Conduct of Transfer

• Patient should have:– Reliable IV access (x2)– Invasive arterial pressure

monitoring/ECG/SpO2/CO2– Urinary catheter (Mannitol!!)– Taped ETT (must be secure)– OGT– 20 degrees head-up tilt– Been loaded with Phenytoin

if required (bp drop)– No other unmanaged injury

• You should have:– Adequate training– All the relevant information– Trained assistant– Adequate O2 supply– Supply of drugs esp

sedation/paralysis/ uppers/mannitol and some spare

– Adequate monitoring/infusion pumps and back-up batteries

Common Problems With Solutions• Access to the patient/trailing iv lines/monitoring

cable – Take time “packaging” make checks before you leave

• Dilation Pupil – Increase ventilation/ Increase MAP/ give 100mls Mannitol

• Cough/strain on ETT – Sedate and paralyse

• Seizure – ABC’s and terminate with BDZ

• Ambulance running out of petrol – Make them check before you leave/ Telephone your

destination/ try not to lose your temper

Pitfalls

• If sedation/paralysis are required to secure the airway you must do a focused neurological exam beforehand!! – Document the patient’s best GCS: it is predictive of outcome!

• Pull out lines/ETT getting them off the transfer trolley

Questions?

Summary

• Preparation is everything!• Prevent secondary brain injury by preventing

hypoxia, hypotension and increases in ICP• Take spare drugs/syringes and

needles/monitoring batteries with you• Take a phone with the numbers of your

destination and your base hospital with you

Further Reading

• Recommendations for the Safe Transfer of Patients with Brain Injury. The Association of Anaesthetists of Great Britain and Northern Ireland. 2006

• NICE Clinical Guideline 56: Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults 2007

• Prognostic Value of Secondary Insults in Traumatic Brain Injury: Results from the IMPACT Study. Journal of Neurotrauma Volume 24, Number 2, 2007

• Early Indicators Of Prognosis In Severe Traumatic Brain Injury. The Brain Trauma Foundation. 2007

• Guidelines for the Management of Severe Traumatic Brain Injury. The Brain Trauma Foundation. Journal of Neurotrauma. 2007