What is the management approach for neurotrauma emergencies?

Management of Neurotrauma Emergencies

The management of neurotrauma emergencies requires a systematic approach prioritizing control of life-threatening hemorrhage first, followed by urgent neurological evaluation and intervention for brain injuries to minimize secondary damage and optimize patient outcomes. 1

Initial Assessment and Prioritization

• All exsanguinating patients with life-threatening hemorrhage require immediate intervention (surgery and/or interventional radiology) for bleeding control before addressing brain injuries 1

• After controlling life-threatening hemorrhage (or in its absence), urgent neurological evaluation must be performed, including assessment of pupils, Glasgow Coma Scale motor score, and brain CT scan to determine brain injury severity 1

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 1

Airway and Ventilation Management

• Secure airway control through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring, even during pre-hospital care 1

• Maintain arterial partial pressure of oxygen (PaO2) between 60-100 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1

• Maintain arterial partial pressure of carbon dioxide (PaCO2) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 1

• In cases of cerebral herniation, use osmotherapy and/or temporary hypocapnia while awaiting or during emergency neurosurgery 1

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1

• For adults, a higher target of systolic blood pressure >110 mmHg is suggested prior to measuring cerebral perfusion pressure 1

• Maintain a cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring becomes available, adjusting based on neuromonitoring data and cerebral autoregulation status 1

• Use vasopressors such as phenylephrine and norepinephrine for rapid correction of arterial hypotension 1

Blood Product Management

• Transfuse red blood cells for hemoglobin level <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery (higher threshold may be used in elderly patients or those with limited cardiovascular reserve) 1

• Maintain a platelet count >50,000/mm³ for life-threatening systemic hemorrhage, with higher values advisable for emergency neurosurgery including ICP probe insertion 1

• Maintain prothrombin time (PT)/activated partial thromboplastin time (aPTT) <1.5 normal control during interventions for life-threatening hemorrhage or emergency neurosurgery 1

• During massive transfusion protocol initiation, transfuse RBCs/Plasma/PLTs at a ratio of 1/1/1, modifying this ratio later according to laboratory values 1

Intracranial Pressure Management

• Patients at risk for intracranial hypertension (comatose with radiological signs) require ICP monitoring regardless of the need for emergency extra-cranial surgery 1

• Consider external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1

• For refractory intracranial hypertension, implement a stepwise approach, reserving more aggressive interventions for situations when no response is observed 1, 2

• Elevate the head and upper body by 30 degrees to decrease intracranial pressure by improving venous return from the brain (only in stable circulatory conditions) 3

Imaging

• Perform brain and cervical CT scan without delay in severe traumatic brain injury patients 1

• Consider early exploration of supra-aortic and intracranial arteries using CT-angiography in patients with risk factors (cervical spine fracture, unexplained focal neurological deficit, basal skull fractures, etc.) 1

Special Considerations

• Develop protocols for simultaneous multisystem surgery (including radiologic interventional procedures) in patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery 1

• Avoid inhalational anesthetics including nitrous oxide when raised intracranial pressure cannot be excluded, as they can elevate intracranial pressure through cerebral vasodilation 3

• Restrict physical and cognitive activities during the first days after TBI to minimize symptom exacerbation 2

• Transport patients to neurotrauma centers for definitive diagnosis and life/brain-saving emergency treatments such as decompressive craniotomy 4