Traumatic Brain Injury: Therapy

General measures

  • Immediately make an emergency call! (Call number 112)
  • Ensure vital functions with the aim of normovolemia and normotension; if necessary, administration of a 0.9% NaCl infusion solution
  • Stabilization of the cervical spine should be performed.If the patient has unstable circulatory conditions, it must be weighed whether the installation of a cervical support is mandatory or whether there is another possibility of immobilization. For whole-body immobilization, the vacuum mattress offers better stability and more comfort than the spineboard for this purpose.
  • If possible, a 30 ° upper body elevation should be maintained.
  • Blood pressure drops should be avoided; blood pressure should be maintained in the upper normal range.
  • The indication for intubation (insertion of a tube through the mouth or nose to secure the airway) and artificial respiration should be generous.
  • Attention should always be paid to concomitant injuries.
  • Apply sterile dressings to open wounds, do not remove foreign bodies from wounds.
  • The patient should be transported to a hospital where a computed tomography (CT) scan is available 24 hours and neurosurgical treatment is assured if brain dysfunction is potentially life-threatening.

Secondary damage to the brain must be prevented.

Craniocerebral trauma grade 1: Commotio cerebri (concussion)

  • Monitoring in hospital for 24 hours; children: 12-48 hours.
  • Bed rest for a few days

Craniocerebral trauma ≥ grade 2

Intensive care monitoring or therapy (intracranial pressure management):

  • Patients with a GCS ≤ 8 (children: GCS < 9 or respiratory compromise) are sedated, intubated (insertion of a tube through the mouth or nose to secure the airway or for ventilation), and ventilated.
  • Oxygen saturation (SpO2) (blood) ≥ 90%.
  • Systolic blood pressure ≥ 90
  • Hyperosmolar therapy, to decrease tissue edema; the following substances are used:
    • Mannitol 20%, sorbitol 40% (each i.v. bolus 0.5-0.75 g/kg bw, maximum 4-6 × daily).
    • Glycerol 10% (i.v. 1,000-1,500 ml/d, maximum 3-4 × daily).
    • NaCl 7.5-10 % (i.v. bolus 3 ml/kg bw, up to 250 ml/d).
  • Hyperventilation (lung ventilation increased above the need).
  • Intracranial pressure (ICP) ≤ 20-25 mmHg.
  • Cerebral perfusion pressure (CPP = difference of mean arterial blood pressure and mean ICP) ≥ 50 mmHg.
  • Barbiturate coma (ultima ratio).

Legend

  • Glasgow Coma Scale (GCS) or Glasgow Coma Scale: scale for estimating a disorder of consciousness.
  • ICP = “intracranial pressure” (pressure inside the skull).
  • CPP = “cerebral perfusion pressure” (cerebral perfusion pressure).

Further notes

  • Hypothermia (hypothermia of the body) has shown no benefit in a large randomized multicenter trial of patients after severe traumatic brain injury.
  • Early use of the antifibrinolytic tranexamic acid (loading dose of 1 g over 10 min, then infusion of 1 g over 8 h), which is designed to limit brain bleeding, reduced mortality (death) from brain injury in patients with traumatic brain injury (TBI). The study enrolled patients with moderate or severe traumatic brain injury (≤ 12 points on the Glasgow Coma Scale, GCS) or with evidence of brain hemorrhage on computed tomography. Patients with mild-to-moderate head injury (GCS: 9-15)-here, 5.8% of patients died in the tranexamic acid group and 7.5% in the placebo group-had the greatest benefit, yielding a risk ratio of 0.78, which was significant with a 95% confidence interval of 0.64-0.95.

Nutritional Medicine

  • Enteral nutrition (nutrition via the gastrointestinal tract by means of a stomach tube, PEG tube* or e.g. jejunal tube/small bowel tube used) should also be started early in cases of severe traumatic brain injury.

* Percutaneous endoscopic gastrostomy (PEG) (endoscopically placed artificial access from the outside through the abdominal wall into the stomach).

Physical therapy

  • Start physical therapy early to prevent contractures in unconscious individuals

Complementary treatment methods

  • Low-level light therapy with light in the near-infrared range/light beams in the range of 600 to 1,100 nanometers (mode of action: Cytochrome c oxidase and other enzymes of the mitochondrial respiratory chain are stimulated in their activity by the light therapy) – Changes due to the therapy were observed by magnetic resonance imaging; questionnaire survey gives evidence for some improvement of symptoms.

Rehabilitation

  • Rehabilitation must lead to a gradual resumption of physical and cognitive activity depending on the degree of TBI.
  • Guidance in mild TBI for resumption of competitive sports (“return to play rule”) and school attendance (“return to learn rule”).
    • Athletes should not return to play the same day (“no return to play the same day”) unless they are symptom-free for more than 20 minutes and have an unremarkable examination result; the examiner should also be very experienced.
    • School attendance (“return to learn rule”):
      • Stage 1: physical and cognitive rest: no work, school or sportsScreening from stimuli: light, noise, television, PCFurther recommendation: plenty of sleep.
      • Stage 2: Gradual cognitive load: reading, TV, smartphone, PC, etc.Light, short aerobic exercise (endurance training)Further sports activities as follows:
        • Stage 3: sport-specific interval training.
        • Stage 4: team training without physical contact
        • Level 5: Normal team training
        • Level 6: Competition
  • Furthermore, as far as possible early start of rehabilitation with physiotherapy, occupational therapy, speech therapy.