What is the initial management for a patient with traumatic brain injury in India?

Initial Management of Traumatic Brain Injury in India

The initial management of traumatic brain injury in India must prioritize prevention of secondary brain injury through immediate airway management, maintaining systolic blood pressure >110 mmHg, avoiding hypoxia, and urgent CT imaging, followed by rapid transfer to a specialized neurosurgical center. 1

Immediate Priorities: Prevent Secondary Brain Injury

The cornerstone of TBI management is preventing hypoxia and hypotension, which are the two most critical factors that worsen neurological outcomes and mortality. 1, 2

Airway and Breathing Management

• Assess and secure airway immediately using the AVPU scale (Awake/Verbal/Painful/Unresponsive) 1
• Avoid nasopharyngeal airways if facial trauma is present, especially with signs of basilar skull fracture, as this can cause catastrophic complications 1
• Maintain PaO2 between 60-100 mmHg to prevent hypoxic secondary injury 3
• Maintain PaCO2 between 35-40 mmHg during all interventions; avoid routine hyperventilation except in cases of acute cerebral herniation 3
• Consider spinal immobilization in all cases until cervical spine injury is excluded 1

Circulation Management

• Maintain systolic blood pressure >110 mmHg at all times - this is critical as mortality increases markedly when SBP drops below this threshold 1, 3
• Control scalp bleeding immediately with direct pressure 1
• Administer IV fluids to maintain adequate blood pressure, targeting euvolemia 1, 2
• Use vasopressors (phenylephrine or norepinephrine) for rapid correction of hypotension rather than waiting for delayed effects of fluid resuscitation 1
• Never use permissive hypotension in TBI patients - even a single episode of hypotension (SBP <90 mmHg) significantly worsens neurological outcomes 1, 3

Neurological Assessment

• Assess for Cushing's reflex (hypertension, bradycardia, and apnea) which indicates severe head injury and impending herniation 1
• Monitor pupillary responses for abnormalities indicating increased intracranial pressure 3, 4
• Check blood glucose (GRBS) if altered mental status is present 1
• Perform neurological checks every 2-4 hours for deterioration 3, 4

Wound Management Specifics

• Stabilize impaled objects with bulky dressing; only remove if obstructing airway 1
• For neck wounds: apply occlusive dressing with pressure, but DO NOT apply circumferential wrapped neck bandages 1
• For eye injuries: cover injured eye and avoid direct contact or pressure on the globe 1
• For teeth avulsion: keep avulsed teeth in saline-soaked gauze and transport with patient 1

Urgent Imaging

Perform brain and cervical CT scan without delay - this is the reference standard for identifying primary brain lesions, mass effect, and structural abnormalities. 1, 3, 4

CT Protocol Specifications

• Use inframillimetric sections reconstructed with thickness >1mm 1, 3
• Visualize with double fenestration (central nervous system and bone windows) 1, 3
• Add CT-angiography if any risk factors present: 1, 3
  • Cervical spine fracture
  • Focal neurological deficits unexplained by brain imaging
  • Claude Bernard-Horner syndrome
  • Lefort II or III facial fractures
  • Basal skull fractures
  • Soft tissue lesions at the neck

Transfer to Specialized Center

Immediate transfer to a specialized neurosurgical center is essential - management in specialized neuro-intensive care units with neurosurgical facilities significantly improves survival and neurological outcomes compared to non-specialized centers. 1

India-Specific Context

• GVK-EMRI emergency services achieve average response times of 17 minutes in rural areas and transfer >90% of patients to hospitals within 2 hours 1
• Multi-organizational consensus guidelines developed by NTSI, NSI, and AAPI provide India-specific recommendations for coordinated national-level TBI management 1
• The TBI pilot project at AMC/KGH in Visakhapatnam demonstrates successful implementation of structured hierarchical service provision with appropriate referral systems 1

Critical Pitfalls to Avoid

• Never use hypotensive sedation agents for intubation - this can precipitate catastrophic hypotension 1
• Avoid corticosteroids - they have failed to demonstrate beneficial effects on mortality or neurological outcomes in TBI 3
• Do not delay CT imaging for any reason in severe TBI 1, 3
• Avoid routine hyperventilation except during acute herniation while awaiting neurosurgery 3

Monitoring Tissue Perfusion

• Assess base excess levels, arterial lactate, and urine output as indicators of adequate tissue perfusion 3
• Once in specialized center, target cerebral perfusion pressure ≥60 mmHg when ICP monitoring becomes available 3

Epidemiological Context in India

Road traffic accidents account for 60% of TBIs in India, with falls (20-25%) and violence (10%) comprising most remaining cases. 5, 6 The economically productive age group (21-40 years) is most affected, with male:female ratio of 6.5:1. 6, 7 Hospital mortality ranges from 20-35% with 67% having unfavorable outcomes at 6 months, emphasizing the critical importance of optimal initial management. 6, 7