One of the most serious medical crises is traumatic brain injury (TBI). It has a high mortality rate and is a leading cause of death in children and young adults. The Brain Trauma Foundation's recommendations for prehospital management of traumatic brain injury are heavily influenced. The primary goals of prehospital treatment in patients with brain injuries are to stabilize them, triage them in readiness for care, and alleviate further harm. Efforts are made in prehospital treatment to reduce intracranial hypertension (ICP) and consequent brain lesions and insults, to maintain cerebral perfusion pressure (CPP), and to ensure optimal cerebral oxygen perfusion. In this research paper, the procedure of patient care from the point of injury to a place of definitive care is discussed. The research takes notice of the abnormal of traumatic brain injury in a patient. It additionally discusses the logistics that take place at the point of injury, transport, and the definitive care center to produce optimal patient outcomes.
Keywords: Traumatic brain injury (TBI), prehospital, intracranial hypertension, cerebral perfusion pressure
Traumatic brain injury pre-hospital care
Introduction
Traumatic brain injury is among the top causes of death in the world, especially among young people. Human beings frequently suffer physical injuries, now and in the past. The mechanisms of that and the frequency varies with periods. TBI continues to be a significant cause of morbidity and mortality in current society.
Treatment of TBI victims starts after impact. Trauma requires immediate attention. The less critical complications are at the bottom of the list of priorities. Not urgent, nonetheless, does not mean less important. This paper is a product of a literature search from sources in the past five years on the topic of TBI and its prehospital care. The review shows the vital role of patient management before reaching the hospital. Sometimes when the time, the patient enters the emergency section in the hospital the injury is already significant and secondary injury process are already in progress. The standard of care offered to the patient in the prehospital situation is crucial while minimizing the duration taken to reach the hospital. The main aims of the rescuing medical team are to steady the patient and treat primary damage, to alleviate secondary injury and insults.
Quality prehospital emergency care is crucial to improving the chances of survival in victims of TBI while providing swift transport mechanisms. In this research article, secondary sources are examined to consolidate available information on prehospital care in traumatic brain injury. The paper explores the science behind prehospital care while giving recommendations on how to improve outcomes in the long-term, based on recent studies.
Literature Review
Definition
One needs to understand traumatic brain injury before they can learn prehospital care for patients with such injuries. Traumatic brain injury is also referred to as intracranial injury. It takes place when an impact from outside or acceleration or deceleration forces act on to the brain to cause damage (White & Venkatesh, 2016). Such injuries can be classified by for instance mechanism, severity, and extent. Had injury refers to a larger classification which encompasses injuries of the scalp and skull. Traumatic brain injury can result in physical, social, cognitive, emotional and behavioral deficits. Outcomes are wide-ranging, from full recovery to disability, and to death. Traumatic brain injury results from car accidents, falls, and violence. Trauma in the brain is caused by sudden acceleration or deceleration in the cranium or due to both movement and unexpected impact together. More damage after the occasion of brain injury might be in altered blood flow in the brain and pressure in the skull. Some imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) may be employed (Rosenfeld, et al., 2012).
Mechanisms
There is need to understand the mechanisms of various types of traumatic injury to the brain to be able to set up required protocols of care for a patient. Primary injuries take place during impact and are irreversible. Apart from impact to the brain, the first injury is also sustained by cerebral blood vessels causing vessel disruption. Secondary damage is from a flow of cellular events following the first impact. A couple of pathologic mechanisms are activated, in the first hours of injury including mitochondrial, metabolic, vascular and mitochondrial varieties. Several mechanisms of secondary injury act together in synergy to cause amplified damaging effects. Secondary harm is a result of a direct impact, but secondary insults are distinct occurrences mostly iatrogenic and independent of initial impact. Thorough treatment of major lacerations, hypotension, hypoxia and fluid and electrolyte irregularities show that happenings secondary to brain injury can be manageable (Rosenfeld, et al., 2012)
Prevention of Secondary Injury in the Prehospital Situation
The common sequelae of primary brain injury include cerebral edema, raised intracranial pressure, dysfunctional cerebral autoregulation and changes in cerebral metabolism. External and iatrogenic causes worsen these secondary damaging modes of injury. Patients who sustain many traumas get injuries that affect their cardiopulmonary well-being making them especially susceptible to secondary harm. Secondary injuries are frequent and often predict poor outcomes in patients with a distressing cerebral damage. The extent and length of hypotension show a dose-response kind of trend with a Glasgow Outcome Scale score of three months. The consequences of hypoxia and hypotension, however, do not have a profound an effect as in patients with extracranial trauma. The guidelines to follow before the patient reaches the hospital were advanced by the Brain Trauma Foundation and to normalize critical brain injury care in trauma as well as mitigate secondary insults. The guidelines are executed while preventing and treating the secondary injury in the primary phases of care, which considerably improve results of traumatic brain injury patients (Boer, Franschman, & Loer, 2012). Secondary injury is limited through ways such as careful brain oxygenation, reversal of hypotension and other secondary outcomes.
Brain Oxygenation
A leading cause of death in head injury patients is airway obstruction and aspiration events. It is, therefore, vital to keep the airway patent and to prevent aspiration, with an understanding of the mechanisms of these complications. In normal conditions, the brain is contingent on aerobic metabolism to sustain optimal ATP levels for neural cells to keep active. Aerobic mechanism failure causes energy failure in the presence of anaerobic metabolism. Apnea is common with most head injuries. As a response to hypoxia, cerebral blood flow rises when oxygen partial pressure is at below 50mmHg. Low partial pressure of oxygen takes place in about 46% of patients at emergency departments (Boer, Franschman, & Loer, 2012). Lowered oxygen partial pressure is statistically linked with high mortality in patients.
Control of the airways is critical (Beuran, et al., 2012). Few studies report surprisingly worse outcomes for traumatic brain injury patients intubated outside the hospital. Hypoxia is described as apnea, cyanosis, oxygen saturation below 90%, or oxygen partial pressure below 60mmHg. Hypoxia is common in intubation. There is a risk of desaturation linked with intubation and depends on the beginning of oxygen saturation. It occurs all the time if oxygen saturation is less than or equal to 93% (Beuran, et al., 2012).
Endotracheal intubation is connected with higher ICP, hypoxia, and aspiration. The harmful effects of hypoxia or aspiration before the arrival of disaster medics may be irreversible. Positive pressure ventilation causes increased intrathoracic pressure, thus reducing venous return. That could result in hypotension, and for a patient with hypovolemia, it could impair cerebral perfusion pressure. Moreover, sedative medications administered in rapid sequence induction may lead to hypotension. Prehospital intubation delays transport. Endotracheal intubation in the ground increases the incidence of excessive hyperventilation which is shown to adversely influence outcomes (Lossius, Røislien, & Lockey, 2012).
Management of the airway and preventing hypoxia are priorities. Patients should get additional oxygen to have saturations above 90% (Rosenthal, Furmanov, Itshayek, Shoshan, & Singh, 2014). At the prehospital scenario, intubation is a backbone technique for patients with critical head injury and GCS scores less than or equaling eight both to maintain oxygenation and to prevent aspiration. Prehospital recommendations of the brain trauma foundation are that unconscious or unresponsive patients with less than 9 GCS points or those who cannot hold adequate airways, as well as those with hypoxemia in spite of supplemental oxygen. They are intubated. For a head injury patient in a coma, orotracheal intubation is preferred to nasotracheal intubation. That is because the status of basal skull fractures may be unknown and could be worsened inadvertently trying to intubate through the nasopharynx. Physical stimulation of nares might increase ICP as well. The process of intubation allows enough oxygen to perfuse and also lessens hypercarbia is an agent of ICP. Without signs of increased ICP, patients should not still receive prophylactic hyperventilation (Rosenthal, Furmanov, Itshayek, Shoshan, & Singh, 2014).
Hypotension
Hypotension is strongly linked with worsened outcomes in head injury. Hypotension is strongly connected with higher mortality rate. Around 11% of victims suffering critical head injury incur hypotension on the site of damage or the definitive medical facility. Hypotension does not result in isolated head injury. The brain is protected from hypoxia with its capability to absorb oxygen if brain perfusion is retained. Hypotension is a more significant predictor of adverse outcomes than hypoxia. Cerebral ischemia is widely seen in patients who die due to a head injury. It shows loss of autoregulation, and the perfusion to the brain fully depends on the systemic blood pressure. Hypoperfusion and ischemia in the brain are a result of lowered blood pressure. Physical injury increases the risk of harm from ischemia and neuronal injury. Low cerebral blood flow volumes commonly occur hours immediately after a brain injury. Brief hypotension may occur even without blood loss to cause irreversible cell death to injured neurons. It is contended that accessing the intravenous route might take extended periods of time and that small amounts would be infused in short transport session which may not have meaningful outcomes. Some people favor deferred resuscitation together with permissive hypotension. They report that giving IV fluids to bleeding patients may worsen blood loss due to hemodilution increased blood pressure, compromised thrombus formation, and disturbance of clotting. Patients with severe brain injury but suffer delayed resuscitation are at a high risk of additional injuries that take place in low CPP. Head injury victims assisted with late resuscitation get progressive intracerebral bulging and more elevated ICP due to a late reestablishment of CBF.
Hypotension at the site of injury should be managed as this raises patient outcomes with severe head injury. IV fluids are to be given to circumvent low blood pressure or reduce the period or amount of hypotension. With scalp lacerations, they should be treated as reversible causes of hypotension (with the rich blood supply of the scalp). Excess bleeding uses up coagulation factors and platelets and may worsen coagulopathy (Beuran, et al., 2012).
The ideal substance used for resuscitation is not defined but is preferably supposed to be isotonic to prevent edematous brain swelling. Normal saline is more isotonic and hence preferred over Ringer’s solution. Solutions with dextrose above 5% are to be avoided. Hypertonic saline could enable maintenance of normal blood pressure in little volumes (Boer, Franschman, & Loer, 2012).
Management of Suspected Raised ICP
Hypoxemia and hypotension can reduce GCS score in patients. The motor portion in a GCS score is the most crucial. A drop of 1 or more points in GCS scores could indicate a growing intracranial mass lesion. An ovoid or asymmetrical pupil means uncal herniation. Other signs include asymmetrical pupils, widened and motionless pupils, decerebrate posture or a consecutive loss of 2 points in GCS scores from a less than nine score. Urgent measures are to be taken when cerebral herniation is detected. Such measures include critical hyperventilation and administration of mannitol (Wakai, McCabe, Roberts, & Schierhout, 2013). Prompt surgical evacuation is also of importance, and precise neurosurgical care is aimed at in a deteriorating GCS score (Haddad & Arabi, 2012).
Raising the osmotic gradient using hypertonic saline or mannitol between blood and the brain causes water to be drawn the brain into the blood vessels. That causes osmotic diuresis and lowered ICP (Rickard, et al., 2014). Ventilation to hyperventilate the patient may alter their intrathoracic pressure and reduce venous return thus higher ICP. Hyperventilation should thus be held in reserve for situations of elevated ICP with imminent herniation of the brain. Carbon dioxide concentration levels in prehospital care should be between 35 and 40 mmHg. Patients with herniating brains should be assisted with hyperventilation to plasma carbon dioxide levels, not below 30mmHg. Manual ventilation with high ventilator assist rates predisposes patients to low carbon dioxide levels (Beuran, et al., 2012).
Temperature
Hypothermia predicts death in trauma patients. Body temperature below 36oC in patients above 16 years of age increases the risk of dying in patients. Induced hypothermia may be beneficial to brain injury through several modes of action. Hypothermia decreases metabolism and then the rate of oxygen consumption. Trembling and catecholamine reaction is regulated for induced hypothermia. Induced hypothermia lasts around 1-2 days or more, paralleled to shorter levels associated with field hypothermia. Lowered body temperatures, even spontaneous may be beneficial to clinical outcomes of traumatic brain injury patients due to reduced intracranial pressure (Rosenfeld, et al., 2012).
Emergency response
The ideal treatment of patients with traumatic brain injury starts with a call of urgency and trying to identify the presence of TBI. That allows for the medical team to send the most suitable group of people to an accident scene. The skillset within a team and the time are taken to assist the patient are paramount to the outcome in a TBI patient. Among the required skills in a team are securing of the airway, intravenous entrance, and administration of mannitol to avert secondary injury resulting from hypotension, low oxygen, and herniation of the brain in the prehospital scenario.
Timing of Treatment
Prehospital stabilization and rapid transport to distinct care are to be custom-made for each patient, uniquely. It is ideal for patients to be assisted in a way that allows them to get surgery to the injury in the first hour (Beuran, et al., 2012). A mode of transport that facilitates immediate definitive care is important and better if allowing patients to receive monitoring and care during the carriage.
Discussion
A sizeable number of sources is used to write the article, exploring prehospital care in traumatic brain injury. TBI is described at first to provide clarity and circumvent misconception. Prehospital care is additionally defined with its full body of aspects.
Prehospital care in TBI is recognized as the first in a chain of stages that determine survival. It is important to stabilize the condition of the patient, to grade their severity, to avert secondary injury while following recommended protocols and procedures when dealing with TBI patients. Without prehospital care, many patients would not reach a medical facility alive or with a chance of improved outcomes. There is broad consensus that processes such as airway management, ensuring oxygenation and normocarbia, avoidance of hypotension, and prevention of hemorrhage are useful in improving survival in patients.
There is a need for highly skilled emergency medical personnel to perform roles around the delicate prehospital care of brain injury. Their roles include giving osmotic agents, intravenous administration of fluids, endotracheal intubation, and inducing hypothermia where the need arises. Such considerations such as the closest neurotrauma facility and modes of transport according to infrastructure mechanisms are to be made. Prehospital care in traumatic brain injury is extensively described in this research paper.
Conclusion
Prehospital care in is done to stabilize patients of traumatic brain injury for transport, to assign the degrees of urgency to patients with lacerations and brain hernias, and to alleviate additional injuries and insults. Well-ordered trauma structures have distinct procedures that allow for revival in the field, methods of transport and emergency are facilities to enable high-quality prehospital care to patients. Prehospital care is fundamental to improving patient outcomes both in the short and long term in traumatic brain injury patients (Juliette Verchère, 2013).
References
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