What is the treatment for brain trauma from a motor vehicle crash?

Treatment of Brain Trauma from Motor Vehicle Crash

Immediate airway control through endotracheal intubation with mechanical ventilation, strict maintenance of systolic blood pressure >110 mmHg using vasopressors without delay, and urgent non-contrast head CT to guide neurosurgical intervention form the cornerstone of management for brain trauma from motor vehicle crashes. 1, 2

Initial Stabilization and Airway Management

Establish airway control as the absolute priority through tracheal intubation and mechanical ventilation, beginning from the pre-hospital period. 1, 2 This is critical because brain-injured patients cannot protect their airway and require controlled ventilation to prevent secondary brain injury.

• Confirm correct endotracheal tube placement using end-tidal CO2 monitoring to maintain normal PaCO2 levels. 1
• Avoid prophylactic hyperventilation, as hypocapnia causes cerebral vasoconstriction and worsens brain ischemia. 3
• Maintain PaCO2 within normal range (35-40 mmHg) using continuous end-tidal CO2 monitoring. 2, 3

Hemodynamic Resuscitation

Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological prognosis and increases mortality. 1, 2 This is particularly critical in motor vehicle crashes where associated injuries and blood loss are common. 4

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation. 1
• Target mean arterial pressure ≥80 mmHg in severe TBI (GCS <8) to ensure adequate cerebral perfusion pressure. 3
• Avoid permissive hypotension protocols designed for torso trauma, as these worsen secondary brain injury. 3
• Use 0.9% NaCl or balanced crystalloid solutions; avoid hypotonic solutions like Ringer's lactate and colloids. 3

Imaging Strategy

Obtain non-contrast CT of the brain and cervical spine immediately without delay to detect neurosurgical lesions such as hemorrhage, herniation, and hydrocephalus. 1, 2 Motor vehicle crashes commonly cause multiple injury patterns requiring rapid identification. 4

• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone). 1
• Do not delay imaging for "stabilization" at facilities without neurosurgical capability. 1

Neurosurgical Intervention Criteria

Surgical evacuation is indicated for: 1, 3

• Acute subdural or epidural hematomas with thickness >5mm and midline shift >5mm require immediate surgical evacuation to prevent herniation and death. 3
• Symptomatic intracerebral hematomas with mass effect. 2
• Hydrocephalus requiring external ventricular drainage. 2
• Depressed skull fractures. 1
• Any cerebellar hematoma >3cm diameter with brainstem compression or hydrocephalus. 3

Perform wide craniotomy covering the entire hematoma to adequately evacuate blood, control bleeding, and prevent reaccumulation; be prepared for decompressive craniectomy if brain swelling occurs. 3

Intracranial Pressure Monitoring and Management

Implement ICP monitoring in severe TBI patients (GCS ≤8) who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy. 1, 2

• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available. 1
• Use sedation (propofol by continuous infusion), CSF drainage via external ventricular drain, or decompressive craniectomy for refractory intracranial hypertension. 1, 2
• Avoid sedation boluses, which cause hemodynamic instability; use continuous infusions instead. 1

Sedation and Temperature Management

• Administer propofol by continuous infusion in combination with normocapnia to decrease intracranial pressure. 1
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications, unfavorable outcomes, and death. 1
• Employ early measures to reduce heat loss, as hypothermia worsens coagulopathy and increases bleeding risk. 3

Coagulation Management

Motor vehicle crashes frequently cause polytrauma with significant blood loss that compounds brain injury severity and mortality. 4, 5

• Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes. 1
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio if needed, then modify based on laboratory values. 1
• Target hemoglobin 70-90 g/L if transfusion is necessary; avoid over-transfusion. 3

Seizure Prophylaxis and Supportive Care

• Implement strategies for detection and prevention of post-traumatic seizures. 1
• Maintain biological homeostasis including osmolality, glycemia, and adrenal function. 1
• Use mechanical thromboprophylaxis with intermittent pneumatic compression; delay pharmacological thromboprophylaxis at least 24 hours until bleeding is controlled. 3

Mild Traumatic Brain Injury Considerations

For patients with GCS 14-15 presenting within 24 hours of motor vehicle crash, obtain non-contrast head CT if any of the following are present: 6

• Loss of consciousness or posttraumatic amnesia with: headache, vomiting, age >60 years, drug/alcohol intoxication, short-term memory deficits, physical trauma above clavicles, posttraumatic seizure, GCS <15, focal neurologic deficit, or coagulopathy. 6
• Patients with normal CT and normal neurologic examination can be safely discharged with appropriate discharge instructions. 6

Common Pitfalls to Avoid

• Never delay neurosurgical transfer for "stabilization" at non-neurosurgical facilities. 1
• Never use hypotensive resuscitation strategies in brain-injured patients. 3
• Never hyperventilate prophylactically; this worsens cerebral ischemia. 3
• Never use sedation boluses instead of continuous infusions. 1
• Never use 4% albumin, as it is associated with increased mortality in severe TBI. 2