Head Injury Management in Adults in Greater Manchester

Transcription

1 GREATER MANCHESTER TRAUMATIC BRAIN INJURY AUDIT GROUP Head Injury Management in Adults in Greater Manchester January 2006 (Supersedes 2003 document A Framework for the Management of Traumatic Brain Injury ) 1

2 Working Group: Mr Steven Barnard, Clinical Governance Manager, Greater Manchester Ambulance Service Mr John Batchelor, Consultant in Emergency Medicine, Clinical Lead in Head Injury Service, Manchester Royal Infirmary Dr Gary Brear, Consultant in Intensive Care, Wythenshawe Hospital; Chairman of Association of North West Intensive Care Units Mr Roy Dudley-Southern, Team Leader of Greater Manchester PCTs Collaborative Commissioning Team, Gateway House, Piccadilly, Manchester (Chair of GM TBI Group) Mr Tom Hughes, Injury Support Manager, Manchester Dr Fiona Lecky, Consultant & Senior Lecturer in Emergency Medicine, Hope Hospital, Secretary of GM TBI Audit Group Ms Tracey Powell, Greater Manchester TARN Co-ordinator Dr Richard Protheroe, Consultant in Intensive Care & Anaesthesia, Lead Clinician in Neuro Critical Care, Hope Hospital Ms Julie Rigby, Consultant Therapist, Community Neuro-rehabilitation, Salford & Trafford PCTs Dr Wolfgang Schady, Consultant Neurologist, formerly Clinical Director for Neurosciences, Hope Hospital Mr Martin Smith, Chairman of GM Trauma Audit and Research Network and Consultant in Emergency Medicine Mr John Thorne, Consultant Neurosurgeon, Hope Hospital Ms Dominique Verplancke, Specialist Nurse for Neurosciences, Hope Hospital Dr Krystyna Walton, Consultant in Rehabilitation Medicine, Birch Hill Hospital; Clinical Lead of the Greater Manchester Neuro-rehabilitation Network Contributors to 2003 Document: Mr Neil Barnes, Clinical Governance Manager, Greater Manchester Ambulance Service Mr Christopher Brookes, Consultant in Emergency Medicine, Hope Hospital Mr Peter Driscoll, Consultant in Emergency Medicine, Hope Hospital Dr Jane Eddleston, Consultant in Intensive Care, Manchester Royal Infirmary, Clinical Lead of the Greater Manchester Critical Care Network Dr Sujit Kumar, Consultant in Emergency Medicine, Oldham General Hospital Dr Yogdutt Sharma, Consultant in Emergency Medicine, Tameside General Hospital Dr James Stuart, Consultant in Emergency Medicine, North Manchester General Hospital 2

3 Dr Mohammed Zahir, Consultant in Emergency Medicine, Royal Oldham Hospital Dr Jonathan Benson, Consultant Anaesthetist, Manchester Royal Infirmary Mr Ajit Sofat, Consultant Neurosurgeon, Hope Hospital 3

4 Contents Executive Summary page 5 Section 1 Background 1.1 The scale of the problem page Incidence of TBI page Prevalence of TBI page Outcome page 8 Section 2 Pre-hospital care 2.1 Prevention of injury page Roadside resuscitation and immediate care page Indications for referral to hospital page The ambulance service page Management of TBI at the scene page 15 Section 3 Care in the A&E department 3.1 Introduction page Triaging of patients with TBI page Minor/mild head injuries page Moderate head injuries page Severe head injuries page 22 Section 4 The neurosurgical unit 4.1 Patient referral page Transfer to the neurosurgical unit page 26 Section 5 In-patient management of nonventilated head injuries 5.1 Observation page Intravenous fluids page Nutrition page Anticonvulsant treatment page Antibiotic treatment page 32 Section 6 Management in the ITU 6.1 Introduction page Communication page General monitoring page Positioning page Neck care page Use of compression stockings page Examination/X-rays page Sedation and muscle relaxation page Ventilation page Fluid therapy and control of blood sugar page Temperature control page Nutrition and prophylaxis against stress ulcer page Control of systemic blood pressure and cerebral perfusion pressure page 38 4

5 6.14 Intracranial pressure monitoring page Management of diabetes insipidus page 39 Section 7 Brainstem death/organ donation 7.1 Background page The diagnosis of brainstem death page Optimisation of organ function page 42 Section 8 Rehabilitation following TBI 8.1 Introduction page The Greater Manchester model for neurological rehabilitation page Rehabilitation in acute care page Intermediate neurological rehabilitation page Management of swallowing problems page Management of spasticity page Prevention of heterotopic ossification page Assessment and management of pain page Patients exhibiting behaviours which challenge services page Management of agitation and confusion page Management of patients who may try to abscond page 55 Section 9 Follow-up 9.1 Introduction page Specialist cognitive rehabilitation teams page Services for people with mild/moderate TBI page Community rehabilitation and support page 60 Appendix 1 Audit of TBI management page 61 A1.1 Updating the framework document page 61 A1.2 Intensive care of patients with severe TBI in Greater Manchester using TARN data page 61 A1.3 Time to theatre for patients with operable intracranial haematomas page 62 A1.4 Head injury management performance according to national standards page 63 A1.5 CT scan availability page 65 A1.6 Neuro-rehabilitation audits page 65 A1.7 Summary page 66 Appendix 2 Greater Manchester Critical Care Transfer Form page 68 Appendix 3 Rehabilitation after TBI summary page 70 Appendix 4 Head Injuries Support Service page 74 Appendix 5 Information & Advice Sheet for patients who have suffered a minor head injury page 75 References page 76 5

6 Executive Summary Head Injury Management in Adults in Greater Manchester represents the second edition of A Framework for the Management of Traumatic Brain Injury, which was launched in May The original document has been revised by the Greater Manchester Traumatic Brain Injury Audit Group in consultation with acute Trusts in Greater Manchester and patient representatives. The aim and general format of the document remains unchanged, this being to guide Greater Manchester clinicians in the management of adults with traumatic brain injury at each stage of the patient pathway: i.e. the pre-hospital environment through to rehabilitation. There have been changes in content. Sections 2 9 have been updated to reflect new national guidelines from NICE, the Royal College of Physicians and the National Service Framework for long term conditions. Section 10, formerly The Future, has now been replaced by an appendix detailing the work of our group. These audits indicate areas where we can work towards improved care for our patients, ranging from better access to early CT scans and neuro-intensive care, to more timely transfers and neurorehabilitation. The NSF for long term conditions has given further impetus to addressing these issues and we are delighted that as a result the Chief Executive at Salford PCT will lead a managed clinical network in neurosciences. We hope that you will find the document useful and look forward to receiving your feedback. Greater Manchester Traumatic Brain Injury Audit Group September

7 Section 1 BACKGROUND Head injury for the purpose of this document can be defined as any trauma to the head, other than superficial injuries to the face. This document aims to inform and assist Greater Manchester healthcare professionals who have responsibility for the management of patients with head injury in the acute and rehabilitative setting. It is focused on the early detection of complications and best care for patients with clinically important brain injury. The chapters have been updated since the first edition in 2003; the first appendix details recent audits of the head-injured patient s pathway. 1.1 The Scale of the Problem Traumatic Brain Injury (TBI) is the commonest cause of death and disability in patients aged < 40 years and a well-documented reason for hospital attendance. Approximately one million patients in the United Kingdom present to hospitals each year with head injuries 1. Around 30% are children under 15 years of age 2. A relatively small but significant minority of patients are left with significant behavioural, cognitive, emotional and physical damage, resulting in severe social and economic effects including marital breakdown, loss of employment and dependence on social services, at significant cost to the community at large About 20% of all patients with TBI seen in A&E Departments are admitted to hospital 4 and each year about 4,000 patients in the UK undergo neurosurgical intervention. Some 63% of adult patients who sustain moderate head injuries and 85% of patients who sustain severe head injuries remain disabled one year after their accident. Even patients with minor head injuries may experience problems including headache, memory loss and poor concentration (13-15%), such that about 12% have not returned to work by 6 weeks 5, Although incidence is high, the mortality rate from TBI is low (6-10 per 100,000) 4. Over the past 30 years, deaths following road trauma have fallen substantially, especially since the introduction of occupant-protective devices, crash helmets and alcohol limits. There has also been an improvement in clinical services, such that patients are now more likely to survive after serious multiple trauma. However, the incidence of head injury in vulnerable road users (i.e., pedestrians and cyclists) remains high and, when calculated on an exposure basis rather than a population basis, can be shown to be rising. Interpersonal violence is also increasing There is evidence that these aetiological factors are more prevalent in deprived communities. Greater Manchester has a greater proportion of vulnerable road users and a higher incidence of violence than the national norm 7. There is also a higher prevalence of chronic disease, which adds to the morbidity and mortality after trauma. Poorer vocational and social background, alcoholism, drug abuse and less than average educational attainment have been cited as more prevalent in adults sustaining a TBI, especially a severe injury 7, than in the population generally The first UK guidelines for identifying high-risk, head-injured patients were drawn up in Modifications have since been published by the Society of British Neurological Surgeons, the Royal College of Surgeons of England, the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Clinical Excellence (NICE) 3,

8 1.2 Incidence of TBI Post-traumatic amnesia (PTA or post-acute brain injury confusional state) is the period following TBI when continuous memory fails because patients are unable to store and retrieve new information. Islands of memory may surface before the end of PTA. Broadly speaking, a head injury will be regarded as mild if the duration of PTA is less than an hour, moderate if the PTA is between one and twenty-four hours and severe if it exceeds a day. The Glasgow Coma Score (GCS, see page 16) after initial resuscitation is now generally regarded as a more reliable indicator of severity for routine clinical purposes than GCS immediately after the injury, the duration of coma or the duration of post-traumatic amnesia. The following criteria are usually applied when defining the severity of a head injury: Mild TBI: an injury causing unconsciousness for less than 15 minutes and a Glasgow coma score (GCS) after initial resuscitation of Moderate TBI: an injury causing unconsciousness for more than 15 minutes and a GCS after initial resuscitation of Severe TBI: an injury causing unconsciousness for more than 6 hours and a GCS after initial resuscitation of Using these definitions, approximately 90% of head-injured patients attending A&E Departments in the UK have a mild TBI, 5% have a moderate TBI and 5% a severe head injury 4. These figures have to be viewed with some caution because of difficulties in ascertainment and in the allocation of patients into the three categories If it is assumed that the Greater Manchester population is roughly 7% that of England and Wales, national statistics can be adjusted to give a general picture of the likely pattern of attendance for the conurbation. Every year 70,000 people will attend Accident and Emergency Departments in Greater Manchester with a TBI. On average, each of the twelve A&E Departments will therefore receive about 6,000 head-injured patients, roughly translating to 16 a day. This represents approximately 10% of their total workload It can be estimated that for every patient who dies from an isolated head injury there is another who has a TBI combined with major extra-cranial trauma. Over 100 patients per annum are discharged from hospitals in Greater Manchester with severe brain damage. There is now recognition that all patients with moderate and severe head injury should be managed in neuroscience units 3. Those with minor injuries are best managed on observation wards in the local accident and emergency department. Children represent special cases and should be managed jointly with paediatricians. 1.3 Prevalence of TBI Studies of prevalence in the community have been able to identify only a proportion of patients with TBI who would have been expected to reside there on the basis of incidence figures. Factors contributing to this discrepancy include a misconceived assumption that lack of obvious physical disability indicates full recovery and a tendency to downward social drift of those with continuing cognitive and behavioural impairments, such that they become marginalised in society and are no longer visible to the health and social care services or, if visible, are not perceived as suffering from the continuing effects of their injury Disabled survivors of severe TBI have a prevalence of /100,000 of the United Kingdom population. In a health district with an average population (approximately 250,000) the number of disabled survivors expected to be living in the district at any one time will be between 250 and

9 1.3.3 Unlike a chronic disease or an impairment such as amputation, which will persist for the rest of the patient s life, the deficits resulting from TBI tend to improve steadily after severe injury. This improvement commonly continues for 3-5 years and in some cases for as long as 15 years. On the other hand, a significant minority (probably about 5%) of patients have been reported to show late deterioration in physical and cognitive functioning Outcome Brain damage after TBI may result from (a) diffuse injury, which ranges from simple concussion to major diffuse loss of axons, or (b) mass lesions. The latter include either haematomas (extracerebral, subdural or intracerebral) or brain contusion, which predominantly affects the frontal and temporal lobes and may be at the site of (coup) or opposite (contra-coup) the injury. The outcome in both instances will depend on the severity of the TBI. Head injury accounts for 1% of deaths from all causes at all ages but 20% of deaths occurring in patients between the ages of 5 and 45 years Minor Traumatic Brain Injury Mild TBI may lead to organically-based deficits of attention, concentration and memory. Three months after minor TBI, 79% of patients have persistent headaches and 59% have memory problems. These deficits normally recover after 3-6 months and should cause persistent disability in less than 5% of cases. However, while present, such deficits are likely to impair the patient s capacity to function normally, particularly when under pressure and at work. Most such patients have some post-traumatic amnesia but the distinction between the psychological reaction to the injury and physical deficits may be difficult to establish. In one study, 3 months after a mild TBI (defined as unconsciousness of 20 minutes or less), 34% of patients who had been gainfully employed before the injury were still out of work 5. Those who were unemployed despite a normal neurological examination had neuropsychological deficits in attention, concentration, memory or judgment. In addition, they showed emotional distress. It is, therefore, incorrect to assume that patients in the mild TBI category have a uniformly good outcome Moderate and Severe Traumatic Brain Injury Many studies have assessed the outcome of neurosurgically-managed patients. Typically they have used a measure such as the Glasgow Outcome Scale, which subdivides surviving patients into permanent vegetative state, severe disability, moderate disability, and good recovery 15. Within the first 6-12 months after injury, approximately 30-40% of surviving patients can be described as having a good recovery or moderate disability. There are a number of problems with such data. Firstly, the patients may not have had access to a coherent rehabilitation programme. Secondly, 6-12 months is much too soon to assess the final outcome. Thirdly, words such as good or moderate may hide considerable degrees of disability. Of the patients with severe TBI who were in employment at the time of the injury, fewer than 1 in 6 returned to their job within 5 years 12. In terms of recovery of physical function, approximately 90% of neurosurgically-managed patients who survive become independently mobile by one year after injury. Those of who do not achieve such a good physical outcome have a variety of disorders. The more severe the injury, the greater is the likelihood of brainstem damage and of complex neurological dysfunction, including spasticity, incoordination, slowness, fatigue and reduced drive. In addition, patients may show disturbances of balance and persisting tremor. If patients have been immobilised for long periods and contractures have developed, further restriction of movement is added to the effects of any neurological impairment. 9

10 Much of the morbidity after TBI is determined by cognitive and behavioural deficits. There is usually gradual improvement and patients may develop new strategies of behaviour over the course of many years. At five years after the injury, deficits in memory, complex information processing, structuring and planning are frequently detectable. Approximately 60% of such patients show tension, anxiety, depression and irritability that may amount to frank aggression 12. The secondary consequences of these changes are serious. Patients are unlikely to succeed in going back to work, often having tried to return and failed because of cognitive or behavioural changes. Family members find their brain-injured relative difficult to accept, with consequent distress, feelings of guilt and a higher incidence of family breakdown. The deteriorating expectations of relatives feed back into the patient s behaviour, causing a downward spiral of increasing demoralisation and social withdrawal

11 Section 2 TBI: PRE-HOSPITAL CARE 2.1 Prevention of Injury The risk of TBI is greater in people who are socially or educationally disadvantaged, poor, unemployed, living in an urban as opposed to rural area, and who have a history of abuse of alcohol or drugs. 25% of all road traffic accidents are associated with alcohol use. Campaigns against drinking and driving can be effective and enforcement of drink-driving laws in conjunction with public education saves lives Some cars are safer than others. More rigorous safety standards in vehicle design would reduce injuries both inside and outside the vehicle. The layout and landscaping of roads and intersections, the design of kerbs and the use of traffic calming measures such as humps, all affect road traffic accident rates. Driving too fast is a major cause of accidents. More rigid and high profile enforcement of legal speed limits would diminish accident rates. The wearing of cycle helmets reduces the severity of injuries sustained by cyclists Roadside Resuscitation and Immediate Care It has been estimated that more than two thirds of people who die from head injury do so before reaching hospital. A review of deaths from TBI among children identified the presence of potentially preventable factors in 22% of cases who died before admission to hospital. Rapid evacuation from the scene of the injury and sophisticated pre-hospital care has been shown to reduce mortality significantly Head injury management is focused on preventing, detecting and correcting secondary insults all the way from the scene of the accident to the Intensive Care Unit or Neurosurgical Ward. The duration and severity of complications, whether systemic or intracranial, influence the outcome. The major threats to a head injured patient are hypoxia and delays in treatment. The former may result from airway obstruction or inadequate ventilation. Hypotension (systolic blood pressure < 90mmHg) has been shown to reduce survival in cases of severe TBI National audits in the UK have indicated that up to 30% of deaths from trauma, after arrival in hospital, are avoidable. Guidelines for the management of severe TBI and an improved referral policy reduce mortality in patients with intracranial haematomas and complex intracerebral lesions. The Department of Health has set minimum standards for ambulance response times for different categories of head injury 3. 11

12 Assessment of Minor Head Injuries GMAS has developed a protocol (figure 1) that enables appropriately trained ambulance staff to advise patients with minor head injuries not to attend hospital. A patient information leaflet has also been produced (Appendix 5)) to be left with the patient. The protocol is based on the latest NICE Guidance for Head Injuries and also audit results of patients not transported to hospital in Greater Manchester during 2003/4. Alternative to Transport Found Protocol for Minor Head Injuries Altered Assess Sensorium Yes to one or more of the following would indicate an altered sensorium. GCS <15 at any time since injury? Any LOC as a result of the injury? Any focal neurological deficit*? Any seizure since the injury? Amnesia post or prior event? Is the patient under the influence of alcohol or drugs? Unaltered *Focal Neurological Deficit Examples include: 1. Problems understanding or speaking. 2. Problems reading or writing. 3. Decreased sensation. 4. Loss of balance or general weakness. 5. Visual changes. 6. Problems walking. C-spine immobilisation required Yes Additional History/MOI Are any one of the following factors present that may indicate a high energy head injury? 1. Fall > 1 metre or > 5 stairs 2. Axial load to the head e.g. diving accident 3. High-speed RTA (> 60 mph), bicycle collision, occupant ejected from a motor vehicle, rollover RTA and motorised recreational vehicles. No Yes Are any of the following present? 1. Any vomiting episodes since the injury 2. Persistent headache since the injury 3. Any previous cranial neurosurgical surgery 4. History of bleeding or clotting disorder 5. Current anticoagulant therapy such as warfarin 6. Any suspicion of a skull fracture or penetrating head injury (e.g. clear fluid running from the ears or nose, black eye with no associated trauma around the eye, bleeding from one or both ears, new deafness in one or both ears, bruising behind one or both ears, visible trauma to the scalp or skull of concern to the ambulance crew). 7. Suspicion of non-accidental injury 8. Age >65 years 9. Continuing concern from the attending ambulance crew No Transfer to A & E Yes Are any of the following present and sufficiently severe in the judgement of the crew. 1. Irritability or altered behaviour 2. Visible trauma to the head not covered above but still of concern to the crew 3. Adverse social factors (for example no one to supervise the patient at home) 4. Continuing concern by the patient or carer about the diagnosis No No referral to A & E required. Complete Patient Report Form, including full record of patient assessment and clinical observations. Complete Minor Head Injury Assessment Pro-forma Leave white copy of PRF with patient. Provide patient with Minor Head Injury Information leaflet. 12

13 Prioritisation categories and response time standards for patients with TBI Category Definition Response time standard Head injury categories A Immediate life-threatening 75% of calls within 8 mins Decreased conscious level; situation requiring urgent falls from a significant height assistance (e.g., a child who falls 3 times its own height); RTA (unless everyone is conscious and without breathing difficulty) B Serious condition which is 95% of calls within 14 mins not immediately lifethreatening C Non-serious or non-life- Respond to 100% within Low energy head injury with threatening but requires 60 minutes minor wound conveyance to hospital A head-injured patient should be referred to hospital if any of the following is present 10. Impaired consciousness (GCS<15/15) at any time since injury Amnesia for the incident or subsequent events Neurological symptoms, e.g. - severe and persistent headache - nausea and vomiting - irritability or altered behaviour - seizure Clinical evidence of a skull fracture (e.g. CSF leak, periorbital haematoma) Significant extracranial injuries A mechanism of injury suggesting: - a high energy injury (e.g. road traffic accident, fall from height) - possible penetrating brain injury - possible non-accidental injury (in a child) Continuing uncertainty about the diagnosis after first assessment Medical co-morbidity (e.g. anticoagulant use, alcohol abuse) Adverse social factors (e.g. no-one able to supervise the patient at home) 2.4 The Ambulance Service A set of guidelines to manage head injuries requiring transport to hospital has been prepared by the Joint Royal College Ambulance Liaison Committee and has been adopted by the Greater Manchester Ambulance Service (GMAS). Initial resuscitation is concerned with assessing and monitoring the patient s state, taking into account time-critical and non-time-critical features. Problems with airway and breathing are corrected at the scene and the patient is transported to the nearest suitable receiving hospital (see page 6), with a hospital alert message en route. In non-time-critical patients, a more thorough assessment can be carried out. 13

14 2.4.2 In some countries patients with TBI are admitted directly to a neurosurgical centre. The EBIC survey showed that 43% of severely head-injured patients who are admitted directly to a hospital with neurosurgical facilities have a shorter injury to neuro care interval (median 1 hour) compared with those transferred by another hospital (median 4 hours). In the UK, secondary transfer from a DGH A&E Department to the neurosciences centre, when needed, is the rule 17, It is evidently important to get the patient to the right hospital at the right time. Local guidelines drawn up with GMAS recommend that patients are taken to the nearest appropriate hospital for stabilisation of their cardiovascular status, appraisal of other injuries and assessment of the severity of the TBI. Facilities for patients with TBI in A&E Departments across Greater Manchester and Eastern Cheshire 24-hour resus 24-hour CT Image link Short stay Transfer facilities FAIRFIELD GENERAL (BURY) planned HOPE (SALFORD) n/a n/a MACCLESFIELD MANCHESTER ROYAL NORTH MANCHESTER ROCHDALE INFIRMARY - ROYAL ALBERT (WIGAN) ROYAL BOLTON ROYAL OLDHAM STEPPING HILL TAMESIDE GENERAL TRAFFORD GENERAL - WYTHENSHAWE 14

15 Summary of Care of TBI at the Scene (see notes below) Ensure careful approach Scene Assessment Gain History (MOI)* ABCDs Administer Oxygen Therapy TIME-CRITICAL FEATURES NON-TIME-CRITICAL FEATURES Full Spinal Immobilisation Vital Signs Load and Go (Blue Light Transport) Secondary Survey Hospital Standby Request Continue to Manage ABCDs Vital Signs en Route Consider I.V. Access Full Spinal Immobilisation Consider I.V. Access Re-assess ABCDs Consider Standby Request Transport to Hospital Secondary Survey *mechanism of injury 15

16 2.5 Management of TBI at the scene The following are time-critical features of TBI: 1. Airway with cervical spine control 2. Breathing 3. Circulation 4. Disability 1. The avoidance of airway obstruction is the first priority in the care of all injured patients but is particularly important in patients with TBI, since hypoxia and hypercarbia raise the intracranial pressure. If there are problems in maintaining a clear airway, paramedical staff have been taught to use (sequentially) jaw thrust, suction, an oropharyngeal airway or a nasopharyngeal airway. If insertion of a tracheal tube is thought to be needed, skilled medical help will usually be obtained faster by transporting the patient straight to hospital than by calling to the scene a doctor who is trained in rapid sequence intubation. The opposite would apply if the patient is trapped and appropriate medical help can be summoned rapidly. All patients with a decreased level of consciousness should have their cervical spine immobilised. A collar should be used when extracting the patient but, once an unconscious patient is correctly placed on a spinal board with head restraints, the collar can be loosened and possibly removed. 2. With regard to breathing, the importance of avoiding hypoxia has already been discussed. All patients should receive a high concentration of inspired oxygen and ideally should have a pulse oximeter applied. This may not be easy in the pre-hospital environment and may be impossible if the patient is cold, vasoconstricted or combative. 3. Turning to circulation, the aim is to maintain the cerebral perfusion pressure above 70 mmhg, which requires a mean arterial pressure of at least 90 mmhg and thus a systolic BP of approximately 120 mmhg. If a patient with TBI is found to be hypotensive, blood loss is probably responsible. External haemorrhage must be controlled by direct pressure. If there is severe haemorrhage and hypotension, IV cannulation and fluid replacement should be undertaken in the ambulance en route to hospital. 4. The prediction of disability in an acutely head injured patient entails the assessment of the conscious level, pupils and motor power. A change in the conscious level is the most sensitive indicator of deterioration or improvement. It should be measured, using the Glasgow coma scale (GCS), as soon as possible and certainly before the patient is anaesthetised. The GCS is one of the components of the revised trauma score, which is widely used for trauma audit (see page 12) Paramedical staff are trained to recognise mechanisms of injury and serious injury patterns, which include: penetrating trauma to the head, neck or chest, serious chest trauma, serious head injury, multiple injuries involving head and chest, spinal cord injury and evidence of hypovolaemia. By contrast, patients are considered to have non-time-critical features when they are alert and responsive, pupillary reactions are normal, they have minor lacerations or contusions, they are haemodynamically stable and there is no evidence of any other serious injury. 16

17 Glasgow Coma Score Eye Opening: Spontaneously To speech To pain None If the eyes cannot be opened due to swelling, this must be documented and the eye score is invalid 4 (eyes open when the patient is at rest) 3 (eyes open when the patient is spoken to) 2 (eyes open to stimulus not inflicted to the face) 1 (both eyes remain closed to painful stimulus) Verbal Response: If speech is impossible due to injury or intubation, this must be documented Orientated Confused Inappropriate words Incomprehensible sounds None 5 (patient knows who they are, where they are, the time/date) 4 (talking/answers questions, but confused and disorientated) 3 (recognisable, but inappropriate words) 2 (grunts/groans, but no actual words) 1 (no sounds at all) Motor Response: The best response in the upper limbs is recorded. For patients not responding to verbal command, a central painful stimulus is applied to the supraorbital nerve, with the arms positioned across the body so that the elbows are flexed to 90 o Obeys commands 6 (responds appropriately to simple commands) Localises to pain 5 (localises painful stimulus above eye) Normal flexion 4 (flexes arm normally to above clavicle, but does not reach stimulus) Abnormal flexion 3 (decorticate flexion of all arm joints, not reaching above clavicle) Extension 2 (extends arms to side of body) No response 1 17

18 Section 3 TBI: CARE IN THE A&E DEPARTMENT 3.1 Introduction The main focus of assessment for head-injured patients in A&E departments should be the risk of clinically important injuries to the brain and cervical spine and the consequent need for imaging. Early imaging, rather than simple observation for neurological deterioration, will reduce the time to detection of life-threatening complications and is associated with better outcomes 1,2. For example, delays of more than 4 hours in the evacuation of an extradural haematoma are associated with significantly worse outcome (greater than two hours for a patient in coma) It is reasonable and appropriate for A&E departments to admit and supervise head injured patients for up to the first forty-eight hours, provided there are satisfactory facilities and suitably trained staff on site. An observation/short-stay ward should be available, ideally within or adjacent to the A&E department. Local arrangements must be made for the onward referral of patients not fit for discharge after forty-eight hours. Only a minority of practising general and orthopaedic surgeons have been trained in the management of head injuries, and the proportion will drop with the advent of new specialist registrar training programmes A report from a RCS working party in 1999 recommended that patients with TBI who require continuing care should be the responsibility of the Neurosciences Centre 3. The implementation of the RCS recommendations depends on the allocation of resources specifically for this purpose. The guidelines in this and subsequent sections reflect current realities in Greater Manchester but it is expected that they will change if funds are set aside to implement the RCS report. 3.2 Triaging of Patients with TBI All head-injured patients presenting to an A&E Department must be assessed by a trained member of staff (e.g., a triage nurse) within 15 minutes of arrival in hospital. This assessment should establish whether they are at a high risk or a low risk for clinically important brain injury and/or cervical spine injury. Patients at a high risk should be assessed by an A&E clinician within 10 minutes of triage In the UK over 70% of patients attending A&E with a TBI currently have a skull X-ray, even though it reveals a fracture in only 2% of cases 23. Work by Teasdale s group showed that the risk of an intracranial haematoma was 1 in 31,300 in adults with GCS 15 and no skull fracture, compared to one in 81 for GCS 15 patients with a skull fracture 24. A more recent meta-analysis found that the sensitivity and specificity of a skull X-ray for predicting the presence of intracranial pathology were 38% and 95%, respectively 25. A CT head scan can directly answer the question whether there is any structural intracranial damage. CT scanning should be readily available, on a 24-hour basis, to A&E departments responsible for assessing head-injured patients. The current NICE guidelines do not advocate the use of skull X-ray unless CT scanning is not available. 18

19 Indications for Cranial CT Scanning (NICE Guidelines 2003) Are any of the following present? GCS < 13 at any point since the injury GCS 13 or 14 at 2 hours after the injury Focal neurological deficit Suspected open or depressed skull fracture Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid otorrhoea, Battle s sign) Post-traumatic seizure > 1 vomiting episode (clinical judgement on cause of vomiting and need for imaging should be used in children 12 years YES NO Any loss of consciousness or amnesia since injury? YES NO Are any of the following present? Age 65 years Coagulopathy (history of bleeding, clotting disorder, current treatment with warfarin) YES NO Are any of the following present? Dangerous mechanism of injury (a pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)? A lower threshold for height of falls should be used when dealing with infants and young children (i.e. < 5 years) Amnesia of greater than 30 minutes for events before impact (the assessment of amnesia will not be possible in pre-verbal children and is unlikely to be possible in any child aged < 5 years of age) Request CT imaging of the head immediately imaging to be carried out within 1 hour of the request 3.3 Mild/Minor Head Injuries GCS 15 YES Request CT imaging of the head immediately imaging to be carried out within 8 hours of the injury, or immediately if patient presents > 8 hours postinjury 19 NO No imaging required now Even within the GCS 15 group there is variability regarding the risk of intracranial abnormality. Such patients can be broadly grouped into four risk categories 28.

20 Indications for Admission of Head-Injured Patients Impaired conscious level Focal neurological deficit Skull fracture Abnormal CT scan Bleeding diathesis or patient on anticoagulants Seizures Persistent vomiting Headache not resolved by simple analgesics Difficulty in assessment - prior neurological disability - mental illness or abnormal behaviour - intoxication Lack of responsible home supervision 3.4 Moderate Head Injuries Patients with a GCS of 9-12 are much less common than those with mild TBI. They all require a CT head scan. The following primary survey should be carried out: 1. Maintain the airway and immobilise the spine. 2. Assess ventilation. 3. Obtain peripheral intravenous access and assess for shock. 4. Check GCS, pupils and lateralising motor signs. 5. Consider whether intubation will be needed (see below). 6. Obtain a trauma series of X-rays (chest, lateral cervical spine, AP pelvis) The above checklist is similar to that used by all emergency departments 32. If there is major chest trauma and a tension pneumothorax is present it should be decompressed and any open wound in the thorax must be closed. A chest drain should be inserted following the primary survey and after intubation. The position and number of chest drains (basal/apical) should be directed by the appearances on the chest X-ray. If shock is present, it should be treated as per ATLS guidelines. Blood products should be immediately ordered if the systolic BP is < 90mmHg Not all patients with moderate TBI require intubation. Those who have an isolated head injury (particularly patients with normal CT scans), are maintaining their airway without assistance and are breathing normally are candidates for spontaneous ventilation. However, they require careful and well-documented neurological observations. The following patients need intubation (for technical details of rapid sequence intubation see next section): 1. Penetrating TBI. 2. Associated major injury to the torso. 3. A deteriorating GCS. 4. When neurosurgery is anticipated, e.g., a large extradural haematoma. 5. Combative patients Alcohol intoxication may also complicate the picture in this group. Agitated intoxicated patients, or those in whom the mechanism of injury is violent, should be intubated and scanned. High serum alcohol levels or a serum osmolarity > 350 suggests significant intoxication. In the presence of a normal CT scan these patients may have a trial of extubation after 24 hours. 20

21 3.4.5 Appropriate imaging of the cervical spine is an important element in the management of patients with moderate/severe TBI 33. Two recent studies have addressed the clinical criteria to rule out injury to the cervical spine in patients with head and upper body trauma 34,35. The following points should be borne in mind: A lateral cervical spine film identifies only 75% of fractures. 93% of fractures will be identified by the combination of lateral, AP and peg views. Most of the missed injuries occur between the occipital condyles and C2 36. The combination of a three-view cervical spine series (lateral, AP and open mouth) combined with CT thin cut axial images with sagittal reconstruction results in a false negative rate of 1% Ideally all patients with a moderate/severe head injury should have: 1. Lateral/AP views (peg views are not usually possible in the intubated patient). 2. CT scan of C0-C2. 3. CT of C7-T1 if this area is not clearly seen. 4. CT of any other suspicious areas after radiological review In patients who are to be transferred to the neurosurgical centre a lateral cervical spine X-ray and CT scanning as outlined above are sufficient. An AP of the cervical spine can be performed at the receiving hospital. The neck should be immobilised until a further evaluation is made at the neurosurgical centre. Even if imaging is normal the possibility of a ligamentous injury to the cervical spine still exists. The reported incidence of this complication varies from 1-8%. 3.5 Severe Head Injuries Patients with a severe head injury (as defined by a GCS < 9) are evidently a medical emergency. They require rapid transfer to the nearest appropriate hospital (page 13) and a comprehensive assessment, incorporating the key points given in the following table: Key Points in the Management of Patients with Severe TBI 1. Primary and secondary survey 2. Maintain an adequate cerebral perfusion pressure 3. Reduce intracranial pressure (ICP) 4. Consider/exclude other causes of decreased conscious level 5. Early CT brain scan (within an hour) 6. Imaging of the cervical spine 7. Imaging of the abdomen 8. Expedient onward transfer The primary survey includes the same steps as outlined in the previous section, namely maintenance of the airway, immobilisation of the cervical spine, assessment of ventilation, treating shock and assessing the GCS, pupils and the presence of motor signs. At the end of the primary survey rapid sequence intubation should be performed Rapid Sequence Intubation (RSI) 21

22 Rapid sequence induction and intubation should only be undertaken by appropriately trained and experienced personnel; they should be familiar with all the equipment, techniques and chosen agents. Cuffed endotracheal tubes (ETT) should be used in the adult head-injured patient. A size 7 or 8 mm internal diameter ETT, cut to 24 cm for female patients and a size 8 or 9 mm ETT cut to 26 cm for male patients should be selected. It is worthwhile having a variety of smaller sized endotracheal tubes available for patients in whom RSI is unexpectedly difficult. A combination of a familiar induction agent and a muscle relaxant should be used in order to ameliorate any rise in ICP. Propofol mg/kg, followed by suxamethonium up to 1 mg/kg should be used to facilitate induction. Care should be taken to avoid hypotension with a running infusion of crystalloid fluid. Alternative induction agents include thiopentone (3-5 mg/kg) or etomidate ( mg/kg). There is no real evidence that etomidate is less likely to disturb cardiovascular stability than other induction agents in the hypovolaemic trauma victim, and even a single dose can produce significant adrenal suppression. If suxamethonium is contra-indicated for neuromuscular reasons, specialist anaesthetic help should be requested. Following successful intubation, sedation should be with propofol (1-5 mg/kg/hr) and fentanyl (5-20 mcg/kg/hr), titrated to response depending on the cardiovascular status. Muscle paralysis should be maintained with a non-depolarising muscle relaxant such as atracurium (0.5-1 mg/kg/hr). Occasionally, the airway is so compromised (major facial trauma and/or oropharyngeal haemorrhage) that intubation from above the cords is unlikely to be successful. If an immediate airway is required, a surgical cricothyroidotomy may be performed. In less urgent cases, alternative methods of intubation and airway control are available, but again specialist anaesthetic help will be required. In the A&E department volume-control ventilation may be safer than pressure-control ventilation. Both airway pressure and volume alarms are mandatory. PEEP should be considered in those patients in whom the FRC is reduced or the closing volume is high. The initial I:E ratio should be set at 1:2 and end-tidal CO 2 should be continuously displayed using capnography, the ideal level being around 4.5 kpa. There may be a difference between the end-tidal and arterial CO 2 of around 0.5 kpa, but it may approach 2 kpa. An arterial sample must be obtained at the earliest opportunity. The patient should ideally be managed in a slightly head-up position to decrease the effects of PEEP on cerebral perfusion and to aid cerebral venous drainage Secondary Survey 1. Central venous access in patients on inotropic support or those with poor peripheral veins. The internal jugular route should be avoided if possible 2. Arterial line for accurate measurement of BP 3. Orogastric tube 4. Urinary catheter 5. ECG 6. Arterial blood gases 7. Capnography in the intubated patient. The maintenance of cerebral perfusion pressure and treatment of raised ICP will be dealt with in the next section. The guidelines for imaging and immobilisation of the cervical spine are the same as for patients with moderate TBI (see Section 3.4). In all patients with a severe head injury a CT head scan is evidently essential once initial resuscitation has taken place, followed by liaison with the neurosciences centre and transfer of images. The recent CRASH trial has shown that there is no place for intravenous corticosteroids in the management of head injury. 89 If a patient presents to the A&E department in coma with a dilated ( blown ) pupil and a clinical picture suggestive of an extradural haematoma (i.e., apparently mild TBI with a lucid interval followed by deterioration), the on-call neurosurgical registrar should be contacted urgently. Immediate scanning is preferable but the patient may need to be transferred following intubation 22

23 and stabilisation without a CT scan if scanning would result in a significant delay in patient transfer (i.e., > 1 hour after arrival in A&E). A lateral cervical spine X-ray should be done as part of the trauma series and the neck should be immobilised until further imaging is performed. 23

24 Section 4 THE NEUROSURGICAL UNIT 4.1 Patient Referral The Neurosciences Centre at Hope Hospital has ten consultant neurosurgeons and thirteen middle grade neurosurgeons. Each day there are two registrars and a consultant on call. Initial referral of patients with TBI should be made through the switchboard at Hope Hospital on (0161) The first-on registrar can be contacted via the baton pager; if he is not available, either the second-on registrar or the consultant will be contacted A logbook is used to record all the referrals. The following information will be requested: Patient name Sex Date of birth Age Referring doctor contact No Referring consultant speciality Hospital Ward Problem Examination Radiology Past medical history GCS (out of 15) Eyes/Motor/Verbal Pupil size and reaction Blood results Advice will then be given about the immediate management of the patient. If appropriate, the scans will be reviewed and the referring doctor (or another named doctor) will be contacted. It is vital that all scans are transferred to Hope via the image link system prior to referral. Any hospital considering renewing their image link system are requested to contact the neuroradiology department at Hope prior to doing so. Criteria for Referral to the Neurosurgical Unit Any patient with a GCS < 9 following a head injury (whether CT normal or abnormal) Patients with a GCS between 9 and 15 with an intracranial clot or parenchymal injury Depressed skull fracture Basal skull fracture with persistent CSF leak Patients with focal motor deficits (even if CT normal) Any patient where there are ongoing management concerns 24

25 All referrals are recorded on a database. A printout recording all information about any referred patient will be sent to the referring unit the next working day. This will include a management plan from the consultant on call on the day of the referral. Any patient requiring immediate neurosurgical intervention from the Manchester region (that served by the Hope Neurosciences Centre) will be transferred to Hope Hospital for their treatment in accordance with the above criteria The neurosurgical registrar on call will liaise with the Intensive Care staff at Hope about patients requiring such care. If a patient needs neurosurgical intensive care but there is no bed available at Hope, it is the responsibility of the neurosurgical unit to liaise with an alternative unit to arrange placement. In the event of the patient requiring emergency neurosurgical treatment but no suitable bed being available at Hope, the patient will be transferred to Hope for that treatment while a bed is arranged If a patient is accepted for neurosurgical intervention, it is the responsibility of the referring hospital to arrange transfer. Secondary insults during transport can worsen outcome, but this risk can be minimised by appropriate resuscitation in the DGH and high level monitoring and care in transport 37,38. When a patient has been accepted for treatment at Hope but immediate transfer is not needed, the neurosurgical registrar will contact the bed manager at Hope Hospital with the patient s details Patients with TBI in need of intensive care but not requiring neurosurgical intervention may be managed in an ITU other than that at Hope Hospital, after discussion between the admitting unit and the on-call neurosurgeon. In such cases daily contact should be made between the hospital where the patient is being ventilated and the on-call neurosurgical team. 4.2 Transfer to the Neurosurgical Unit All patients who are taken from an A&E department to the neurosurgical unit must be accompanied by an appropriate member of staff, relevant documents, X-rays and CT scans and an inter-hospital transfer form. The seniority of the escort will depend on the condition of the patient, which must be judged by the referring hospital. Transfers must follow Greater Manchester Critical Care Guidelines (see Appendix 2). It is particularly important to ensure that the neck is stabilised. Any changes in the status of the patient that occur while awaiting transfer must be passed on to the neurosurgeons at Hope Hospital. Evidence suggests that reducing injury to surgery transfer times to 4 hours in patients with an acute SDH and 2 hours from deterioration in patients with an EDH improves outcome Patients being transferred directly to the Intensive Care Unit at Hope can pass through A&E, but all other ventilated patients with a traumatic brain injury, must stop in the A&E department to be received, and reviewed by a neurosurgeon, prior to being moved to the scanner or theatre The A&E department will be informed by the accepting neurosurgeon of all patients due to be transferred. On arrival at Hope patients will be assessed by A&E staff and steps will be taken to stabilise their condition where appropriate. A member of the neurosurgical team will be in the A&E Department to meet the patient on arrival. Patients going to ITU will be met in A&E by the ITU registrar on-call. Those being taken directly to theatre or for CT scanning will be met in the resuscitation bay in A&E by the anaesthetist on-call and the ODP. It is expected that the transferring team will stay with the patient until the final destination is reached (be it ITU or theatre) to avoid the disconnection of monitoring equipment and transfer from trolley to trolley Patients who are not ventilated will be met by the neurosurgical SHO or registrar in the resuscitation bay in the Accident & Emergency department. They will be assessed and stabilised by A&E staff prior to transfer to theatre or the neurosurgical ward. 25

26 4.2.5 The care of patients with severe TBI should follow the guidelines laid down by the Brain Trauma Foundation and the European Brain Injury Consortium 18,39. The table below identifies currently applicable lines of responsibility in the management of patients with TBI. They are likely to change once resources are put in place for the implementation of the RCS Working Group recommendations 3 Local Hospital Lines of Responsibility Determine which patients can safely go home without admission Organise local admission of patients with relatively mild TBI needing observation for a short period (up to 72 hours) Decide which patients require immediate neurosurgical referral Organise placement of patients not in need of neurosurgical intervention but requiring admission to intensive care Liaise with other specialties regarding non-cranial trauma, whether or not the patient is due to be transferred to the neurosurgical unit Neurosciences Centre Accept patients requiring emergency neurosurgical intervention Organise the transfer of patients in need of neuro-intensive care to a suitable unit, whether it is at Hope or elsewhere Arrange admission of patients requiring non-emergency neurosurgical intervention when a bed becomes available 26

27 Section 5 IN-PATIENT MANAGEMENT OF NON-VENTILATED HEAD INJURIES 5.1 Observation All non-ventilated patients with TBI should be observed at regular intervals, including blood pressure, pulse, respiratory rate, pupillary size and response and Glasgow coma score. High levels of consistency in the interpretation of the GCS can be achieved if training in the use of the scale is provided and reinforced 40. Observations should be performed at least every 30 minutes until a GCS of 15 has been achieved. The minimum frequency of observations for patients with a GCS of 15 should be half-hourly for 2 hours, one-hourly for four hours, and two-hourly thereafter 8, If a drop in the GCS occurs a member of the medical staff should review the patient 29. An assessment should be made of blood gases, electrolytes and recent drug administration. If no cause can be found for the deterioration a CT scan should be performed. If this shows an abnormality the neurosurgical team, if not already involved, should be contacted. The following are given in the NICE report as reasons for prompt urgent reappraisal by the supervising doctor 8. Development of agitation or abnormal behaviour A sustained (that is, for more than 30 minutes) drop of one point in the GCS level Any drop of two points in the GCS regardless of duration Development of severe or increasing headache or persistent vomiting New or evolving neurological symptoms or signs such as pupillary inequality or asymmetry of limb or facial movement If the GCS drops below 15 the observations should revert to half hourly. 5.2 Intravenous Fluids Those not able to drink should be given three litres of normal saline intravenously per 24 hours. Patients on full intravenous replacement will require daily blood tests for urea and electrolytes. 5.3 Nutrition Lack of adequate nutrition of head-injured patients increases the mortality rate due to nitrogen wasting. At this stage it has not been established that one method of feeding is better than another but a consensus document endorses enteral over parenteral feeding 41. Naso-gastric feeding should be started at 24 hours unless there is CT evidence of a fracture in the anterior fossa or skull base. Specific guidelines have been developed by speech therapists and dieticians regarding progression to PEG feeding. This is generally required if it is thought enteral feeding will be needed for more than two weeks. 5.4 Anticonvulsant Treatment Prophylaxis 27

28 Seizure activity in the early period following head injury may cause secondary brain damage as a result of increased metabolic demands, raised ICP and excess neurotransmitter release. However, there is no evidence that the prophylactic use of anticonvulsants at any time after head injury reduces death or disability. There is evidence that they reduce early seizures (in the first week after head injury) by approximately 10%, but this is not associated with any difference in neurological outcome. The use of prophylactic anticonvulsants at any time after head injury does not diminish the incidence of late onset seizures 42. If a decision is made to use an antiepileptic drug, the rationale needs to be stated explicitly in the case notes. As indicated above, there is no evidence that such a strategy prevents later seizures, yet there is a risk of adverse effects. Anticonvulsants prescribed for prophylaxis should be weaned off after one month Treatment of Seizures A fit occurring at the time of head injury is classed as a provoked seizure. Unless prolonged, it does not require the use of an anticonvulsant either in the short or long term. Seizures occurring subsequently in the course of a head injury should be treated. They are often isolated fits of short duration. Any seizures should be documented in a way that their type is clear, i.e., generalised or partial. The following diagram gives guidance on the choice of anticonvulsant 43. First-line treatment of seizures in patients with TBI Generalised or unclassified seizures Partial seizures Male Female (non-childbearing) Female (childbearing) Sodium Valproate Lamotrigine Carbamazepine or Lamotrigine The above table reflects currently accepted practice. Initially, single anticonvulsants should be introduced at a low dose and cautiously escalated up to a standard maintenance dose (as recommended in the BNF). If seizures continue the dose should be increased to the maximum tolerated before switching to an alternative single drug. Combination therapy should be used only if seizures continue despite adequate trials of monotherapy with two appropriate drugs in therapeutic doses

29 1. Sodium Valproate The usual starting dose is 600 mg daily given in two doses. However, if using the liquid preparation, a lower or higher starting dose is advisable because of the difficulties in administering 300 mg accurately (the liquid formulation is 200 mg per 5 ml). The dose is usually increased by 200 mg every three days up to mg per day, depending upon seizure control. Plasma levels may be measured when poor compliance or side-effects are suspected, though they are not helpful for routine monitoring. 2. Carbamazepine The usual starting dose is mg bd, increasing gradually to mg daily dependent upon seizure control and development of adverse effects. In some cases mg may be required. A given dose of the liquid preparation will produce higher peak levels than the same amount in tablet form. It is therefore advisable to start at a lower dose and increase slowly. The use of carbamazepine following brain injury may be limited by adverse effects, e.g., drowsiness, dizziness or cognitive impairment. Carbamazepine may be particularly useful in patients who display behavioural difficulties with agitation or aggression. Full blood count and liver function tests should be checked prior to commencing treatment. 3. Lamotrigine Its use may be limited in the acute situation by the need to start at very low doses, increasing over several weeks to reach a therapeutic level. The initial dose in patients not taking valproate is 25 mg daily for 14 days followed by 50 mg daily for 14 days. The dose can then be increased by a maximum of mg every one to two weeks until the optimum dose is achieved ( mg daily). One of the benefits of lamotrigine is that it is unlikely to have an adverse effect on cognitive functioning. In the early stages following acquired brain injury it is probable that a patient will be commenced on either valproate or carbamazepine for seizure control. This will be reviewed when the patient is transferred to a rehabilitation setting, when the clinical needs may change. 4. Phenytoin By and large, phenytoin should be avoided for the following reasons: Multiple drug interactions Poor absorption during enteral feeding with the possibility of later rebound toxicity Need for monitoring of drug levels in view of the drug s complex pharmacokinetics Adverse effects on cognitive function Treatment of prolonged seizures The immediate treatment in someone who is fitting depends on whether there is IV access. If not, a 10 mg rectal suppository of diazepam or 10 mg of buccal midazolam would be appropriate. If there is IV access diazepam 10 mg at a rate not exceeding 5 mg per minute or a 4 mg bolus of IV lorazepam is recommended. Either can be repeated once after 15 minutes, though not if benzodiazepines have been used previously by another route. If fitting has continued for 30 minutes in spite of the above treatment, the algorithm on page 30 should be followed 42,43. 29

30 Status Epilepticus Algorithm Airway High flow oxygen YES VASCULAR ACCESS? NO Lorazepam 4 mg IV Diazepam 10 mg PR or Midazolam 10 mg buccal or intranasal 15 minutes 10 minutes 15 minutes Lorazepam 4 mg IV YES VASCULAR ACCESS? Fosphenytoin 15 mg PE/Kg IV at 150 mg/min, then continuous infusion OR Phenytoin 15 mg/kg IV at 50 mg/min, then 100 mg every 6-8 hours CALL CRITICAL CARE OR ANAESTHETIST RSI with thiopentone 4 mg/kg IV If already on phenytoin, seek advice from neurology SpR on-call at Hope 30

31 1. IV Fosphenytoin Fosphenytoin is a pro-drug of phenytoin and has significant advantages in ease and safety of administration over traditional phenytoin. It is water soluble and can therefore be infused intravenously up to three times as fast as phenytoin; it causes less pain and burning at the injection site; and it can be given IM in non-emergency situations. The dose of fosphenytoin is calculated as phenytoin equivalents (PE). 1.5 mg of fosphenytoin is equivalent to 1 mg of phenytoin and therefore corresponds to 1 mg PE. The loading dose is mg PE/Kg at mg PE/min. The maintenance dose is 4-5 mg PE/Kg/day by IV infusion at mg PE/min, or by IM injection, adjusted according to therapeutic drug monitoring. 2. IV Phenytoin Phenytoin is licensed for the control of status epilepticus and the prevention of seizures occurring during or after neurosurgery. A loading dose of mg/kg is given at a rate not exceeding 50 mg per minute (due to the risk of hypotension and arrhythmias). Phenytoin is very irritant and incompatible with 5% glucose and therefore must be administered in 200 ml of 0.9% sodium chloride into a large vein. ECG monitoring is essential while giving the infusion, as cardiac arrhythmias (in particular bradycardia and ventricular fibrillation) may occur. Maintenance dosing should begin 12 hours after the loading dose has been given. The BNF recommends 100 mg every 6-8 hours but it is acceptable to use a single daily dose of 300 mg (3-4 mg/kg). Levels should be monitored after two weeks and adjustments made to compensate for increased phenytoin metabolism and low albumin concentrations in critical illness. There is little point in checking the blood level in the early stages of oral treatment because it takes two weeks to stabilise. The disadvantages of phenytoin have already been mentioned above. It is effective but it has a narrow therapeutic index and is an enzyme inducer and therefore interacts with many other drugs and alcohol. Long-term use of phenytoin is associated with cognitive dysfunction, gingival hyperplasia and haemopoietic disorders. If phenytoin has been used to control status in the early stages after TBI, it should be substituted in the recovery period for one of the drugs recommended on page 27, i.e., valproate, carbamazepine or lamotrigine. 3. IV Valproate Sodium valproate is not licensed for treatment of status epilepticus but in some cases it has been used. It does not cause the sedation and respiratory depression associated with benzodiazepines and barbiturates or the hypotension that may occur with barbiturates and phenytoin. It is not an enzyme inducer and oral sodium valproate is 100% bioavailable, so intravenous and oral dosing are interchangeable depending on the patient s condition. Liver function tests should be checked. The manufacturer recommends mg (up to 10 mg/kg) as a slow bolus over 3-5 mins followed by a continuous infusion to make the total loading dose up to 2.4 g over the next 24 hours. It can be administered in sodium chloride 0.9% or glucose 5%. Maintenance doses starting at 300 mg bd should begin 12 hours after the loading dose is completed. Control of seizures is usually achieved within the dosage range of mg/kg/day ( mg/day). 5.5 Antibiotic Treatment There is little evidence that prophylactic antibiotics are of benefit in head injury. Aspiration pneumonia should be treated according to Trust guidelines. Antibiotics should be used for short 31

32 periods, if it all. Patients with skull base fractures and orogastric tubes in place often have an overgrowth of staphylococcus aureus in their nasopharynx, leading to a risk of staphylococcal pneumonia. It is therefore imperative that good toileting of nasopharynx, oropharynx and mouth is undertaken. 32

33 Section 6 TBI: MANAGEMENT IN THE ITU 6.1 Introduction Patients with a severe TBI need to be treated in an Intensive Care Unit. They will be accepted after discussion between the A&E staff, the ICU consultant and the neurosurgical team. Following guidelines laid down in previous sections, a decision will be made whether the patient should go to the ICU in the accepting hospital or to the Neurosciences Centre. All patients with a severe enough head injury to require admission to the ITU should be treated in the Neurosciences Centre Communication In addition to communicating with ICU staff about a patient s referral, the on-call neurosurgical registrar will see all patients with TBI admitted to the ICU at the Neurosciences Centre. Documentation of the visit in the notes should include: a) Parameters for maintenance of ICP/MAP if outside normal protocol b) Time of next CT scan c) Any requirement for antibiotics/anticoagulants/antiepileptic drugs d) If post-operative, instructions for drains, clips, etc e) Other instructions Discussions with relatives should be held jointly by neurosurgeons and intensivists. All conversations with relatives must be recorded in the relatives communication section of the ICU notes. The patient should be assessed jointly by the two teams every day, and both should write in the patient s notes daily. Subsequent joint case review/audit is strongly recommended. When a patient with a severe TBI is managed in a local hospital, the referring intensive care team should contact the on-call neurosurgical registrar daily for an update on the clinical evolution and management. The ITU staff at Hope Hospital will also be available for discussion. 6.3 General Monitoring An important goal in the management of patients with severe TBI is the prevention of secondary ischaemic insults, which occur in up to 90% of patients in neuro-intensive care units 44. They reflect an alteration in cerebral blood flow regulation secondary to hypoxia, hypotension, acidosis and intracranial hypertension. The fact that ischaemia is a delayed secondary event in TBI raises the possibility of a therapeutic window during which the process may be ameliorated Haemodynamic Monitoring A minimum of central venous pressure monitoring will be needed to allow assessment of the volume status prior to the use of vasopressor agents, which also require central venous access for delivery. Invasive arterial monitoring is essential to monitor the effects of these agents and allow calculation of the cerebral perfusion pressure (CPP). Pulmonary artery catheterisation, or alternative less invasive techniques such as the Lidco, may be necessary in some patients in order to optimise fluid balance, cardiac output and vasoactive therapy. This will allow maintenance of an appropriate MAP and thereby an appropriate CPP. 33

34 6.3.3 Arterial Blood Gases ABGs should be monitored with sufficient frequency to confirm that the pco 2 and po 2 are maintained in the required range. Capnography allows the continuous monitoring of trends in pco 2. The end-tidal CO 2 recording on the monitor when the sample is taken should be recorded with the blood gases. The goal of therapy is to maintain normocapnia or a slightly reduced pco 2 ( kpa) Temperature Central and peripheral temperature should be continuously monitored. There is debate on how this is best done, since the relationship between temperature in the brain and elsewhere is not known. Core temperature should be measured hourly by an appropriate method, i.e., a rectal probe Blood Glucose The blood sugar should be checked by glucometer reading and with the laboratory on admission and then monitored two-hourly. The goal is to maintain tight blood glucose control. In headinjured patients hypoglycaemia may be more harmful than mild hyperglycaemia and therefore maintenance of blood glucose should be 6-8 mmol/l. 6.4 Positioning Tilt Patients should be nursed with 30º head-up tilt, assuming that cerebral perfusion pressure can be maintained. If the thoraco-lumbar spine has not been cleared, the whole bed will have to be tilted head up Neck Care The spine must be assumed to be unstable until an appropriate senior clinician reviews adequate films. The neck should cleared early in the course of the admission, but occasionally patients will arrive on ITU without clearance. In these circumstances a collar will be in situ, but if left on for long it may lead to pressure sores in the occiput and/or neck and chin. Unless the patient is to be woken and extubated immediately, an effort must be made to clear the spine at the earliest opportunity The process of cervical spine clearance is as follows: Full cervical views (AP, lateral and odontoid) CT of the atlanto-occipital junction and the distal cervical spine if it cannot be visualised on the plain X-rays At this stage the collar can be removed, accepting that a small number of patients may have an unstable ligamentous injury that will only be identified after extubation. Static flexion and extension views are inappropriate in an unconscious patient. Dynamic fluoroscopy, although more appropriate, is difficult to do in the ICU environment. Magnetic resonance imaging is the most sensitive means of identifying a ligamentous injury Patients with proven ligamentous damage, with or without a cord lesion, should be managed with an appropriate orthosis, which may include halo thoracic fixation after discussion with a neurosurgeon or spinal surgeon. At that stage they should be re-evaluated using dynamic imaging. Patients who in the early stages have unilateral motor signs (i.e., a hemiparesis) may have a carotid dissection rather than a cord lesion. The former possibility can be pursued by MR 34

35 angiography. If a carotid dissection is proven the patient should be discussed with a neurologist and anticoagulation should be considered. 6.6 Use of Compression Stockings Forty percent of patients with traumatic brain injury have increased fibrinolytic activity and 8% have overt DIC. Consequently, there is a significant procoagulant systemic effect. However, in the presence of contusional brain damage there would be a risk of cerebral bleeding if anticoagulants were introduced in the early stages. Instead, patients should be treated with mechanical calf compression devices for the first five days, after which it is safe to use pharmacological prophylaxis. In a patient with a proven DVT and suspected pulmonary emboli who cannot be anticoagulated, the introduction of an inferior vena cava filter may be needed. 6.7 Examination/X-rays Chest X-rays will be needed to confirm placement of the endotracheal tube and central line. Pelvic and spinal X-rays must be done if not already available. A full examination should be carried out to exclude other injuries. A spinal board should be used for interdepartmental transfers Although this document is designed to look at issues related to isolated TBI, some consideration should be given to the management of patients with other injuries. Of particular relevance is (1) the timing of fracture fixation for long bone and/or facial fractures; (2) provision of antibiotic prophylaxis in patients with these fractures; and (3) discharge arrangements for patients with multiple injuries. 6.8 Sedation and Muscle Relaxation In patients with a severe TBI neuromuscular blockade should be reserved for specific indications (e.g., intracranial hypertension and transport 41 ). Muscle relaxants may be used to control continuously raised ICP. The ideal sedative regime for patients with TBI, certainly in the shortterm, is propofol and a short-acting, easily eliminated opiate. The use of these drugs will allow rapid assessment of neurological function and not interfere with brainstem function tests. Caution must be applied if propofol is used for more than 3 days or in doses of >5 mg/kg/hr. Administration for >72 hrs is associated with a rise in triglyceride concentrations. Recent reports of an increased mortality risk due to cardiac failure have cast doubt on the use of high rates of propofol infusion (>5 mg/kg/hr) The use of muscle relaxants to control ICP has a number of disadvantages, namely (a) seizure activity cannot be identified; (b) muscle relaxants may contribute to muscle breakdown in critical illness and delay recovery; (c) retrospective review of muscle relaxant use has not shown obvious advantages; and (d) muscle relaxants are associated with an increase in nosocomial pneumonia. 6.9 Ventilation Cerebral vasospasm and hypoxia are important complications of head injury and will be aggravated by hyperventilation. The pco 2 should therefore be maintained in the normal range ( kpa). Hypoxia should be avoided by maintaining the po 2 above 11 kpa. There is also some evidence that running the patient s po 2 at supra-normal values may improve cerebral metabolism, so inspired oxygen should be kept above 40% 51. Pressure control ventilation techniques are now accepted as the norm. Some ventilated patients with TBI will require a tracheostomy in order to protect the airway from ongoing bulbar dysfunction and to aid weaning from the ventilator. Percutaneous techniques are now commonplace and practical. Most of these patients will be discharged from critical care beds 35

36 with their tracheostomy in situ. For cleaning and safety reasons, it is essential that the tube be changed to a double lumen tracheostomy tube prior to transfer from the ICU. Such patients should be followed up by the critical care service, rather than leaving it to ENT or physiotherapy, until the patient is de-cannulated or discharged from hospital Fluid Therapy and Control of Blood Sugar Hyperglycaemia is associated with a worse prognosis after TBI. Recent studies suggest that controlling the blood sugar may improve outcome 52. It should therefore be monitored 2-hourly and an insulin sliding scale should be used to maintain the blood sugar at 6-8 mmol/l Replacement fluids containing dextrose should not normally be used. This is due to their effect on blood sugar and the osmotic effects on the brain. Volume replacement should be adequate to maintain cerebral perfusion pressure. The preferred fluid is 0.9% sodium chloride In the majority of patients the volume status can be adequately judged by careful examination of peripheral perfusion and temperature gradient, central venous pressure, urine output, response to fluid challenges, arterial waveform and possible sites of covert blood loss. If this is not possible a pulmonary artery catheter may be required. A haemoglobin concentration of more than 80 g/l is adequate with no further need to transfuse blood, unless other indications are present Temperature Control TBI may be associated with hyperpyrexia, both because of the effects of the injury and because of secondary infection, which results in a worse neurological outcome. Aggressive reduction of the core temperature to 33ºC centrally has not been found to be of any long-term value 53. In patients with intracranial hypertension such an intervention leads to effective reduction in pressure but no sustained benefit. In fact, these patients occupy more hospital days due to complications of the hypothermic regime. Nevertheless, it remains a rescue therapy in intractable intracranial hypertension. Peripheral temperature should be measured continuously The core temperature can initially be reduced with paracetamol 1 g qds and the use of a fan. If this is not effective the ventilated patient should be paralysed and active cooling measures used (ice packs in groins/axillae, cold water blankets). Ibuprofen can be given if there is no evidence of intracerebral bleeding. Patients with multiple trauma may be adversely effected by hypothermia, so their temperature should be kept normal Nutrition and Prophylaxis against Stress Ulcer Patients should have an oro-gastric tube passed if a skull base fracture cannot be excluded. Enteral nutrition with approximately 1.5 l/day of feed (depending on dietician s advice) must be established from the time of admission. Early consideration should be given to a gastrostomy for jejunal feeding, once the ICP is stable, in patients with anticipated delayed recovery. The standard feed for each unit should be used, taking into account individual patient requirements. Predigested feeds are not necessary Additional measures to reduce the incidence of acute upper GI bleeding should be implemented, e.g., sucralfate 2 g tds or a proton pump inhibitor, until the patient is receiving full enteral feeding or is no longer ventilated and does not have any other risk factors such as a coagulopathy or renal failure. 36

37 6.13 Control of Systemic Blood Pressure and Cerebral Perfusion Pressure Control of Systemic Blood Pressure Hypotension (SAP<90 mmhg) during intensive care was the strongest predictor of poor outcome in a review of admissions logged on the traumatic coma data bank 54. It would therefore seem reasonable to maintain arterial pressure in excess if 70 mm Hg regardless of the cerebral perfusion pressure. This can be achieved by correction of blood loss and the use of vasopressors in many cases. Occult hypovolaemia must be looked for before these drugs are started. This will require careful examination of peripheral perfusion and temperature gradient, central venous pressure, urine output, response to fluid challenges, arterial waveform, possible sites of covert blood loss or even measurement of pulmonary artery pressures and cardiac output Maintenance of Cerebral Perfusion Pressure The management of cerebral perfusion pressure has been shown to improve outcome in a study with historical controls 55. A vasodilatory cascade is postulated, such that falls in cerebral perfusion aggravate cerebral vasodilation, thereby increasing ICP and further compromising perfusion. The CPP should be continuously displayed and both ICP and MAP should be measured at the level of the external auditory meatus. The mean CPP should be maintained in excess of 70 mm Hg Cerebral Perfusion Pressure (CPP) Monitoring The cerebral perfusion pressure is determined by subtracting the intracranial pressure (ICP) from the mean arterial pressure (MAP). The CPP has been shown to contribute substantially to the overall outcome 59. Using a target CPP of >70 mmhg, target-driven therapy has become an accepted regime. Optimising the CPP requires the presence of an ICP monitor to calculate it and monitor any changes Intracranial Pressure Monitoring Introduction Intracranial pressure (ICP) monitoring is a source of controversy among those dealing with neurotrauma. A consensus document from the American Association of Neurological Surgeons states that ICP monitoring is appropriate in patients with a severe TBI 39. Despite the suggestion that it is of value, reviewers of the subject have felt that the studies evaluating ICP monitoring are inconclusive 56. No randomised prospective study of ICP monitoring has been undertaken. Nonetheless, many intensivists consider that ICP monitoring is advisable in sedated and ventilated patients with a severe TBI, unless they are to be imminently woken for assessment or transferred to a neurosciences centre. If the Neurosciences Centre does not have the capacity to accept all patients with severe TBI, some of them will be managed in other hospitals, though not all ITUs have the necessary equipment or skills to insert an ICP monitor and interpret its findings. In future, all such patients will be treated in the Neurosciences Centre. 37

38 Interpretation The resting normal ICP represents an equilibrium of brain tissue, interstitial water, CSF and blood. An increase in the volume of any of these will lead to a rise in ICP, once compensatory mechanisms have been exhausted. Intracranial pressure correlates with outcome following head injury and the critical threshold is regarded as 25 mmhg by consensus 57. Intracranial pressures greater than this, which do not return to more acceptable levels within five minutes or remain persistently elevated, require further investigation and possibly therapeutic intervention, as follows: Check patient is appropriately sedated Optimal patient position, i.e., 30 degree head-up tilt. Check for venous obstruction: endotracheal tubes should be tied and surgical collars loosened if necessary, with the neck maintained in the neutral position. Check the ventilation is to low/normal pco 2 (~4 kpa). Ensure the patient is not fitting; treat with benzodiazpines if necessary Ensure the patient is not coughing; paralyse if patient is appropriately sedated. Ensure the patient is at least normothermic and actively cool if necessary to achieve a target temperature of 37 o C or less. Give a bolus of sedation. If the ICP remains elevated the neurosurgical registrar should be informed and further advice requested. It is important to exclude an expanding haematoma at this stage. A repeat CT scan would be appropriate to exclude the need for surgery. Further therapeutic intervention may be required as follows: Osmotic dehydration with mannitol (0.5 g/kg), diuresis with frusemide (10-20 mg), or a bolus of hypertonic saline. Boluses of sedative agents or paralysis may be required 58. A bolus of thiopentone (250 mg over 5 minutes) is an acceptable alternative at this stage. The evidence for mild hypothermia, barbiturate coma and hypotonic saline is still equivocal at best and these management strategies should be left to the Neurosciences Centre. Increase the CPP to 90 mmhg and observe the effects on the ICP. If the ICP rises, the cerebral reactivity has been lost (a poor prognostic sign) and the CPP should be returned back to more normal levels. Indications Intracranial pressure (ICP) monitoring may be helpful in patients with severe TBI who have evidence of cerebral oedema, subarachnoid haemorrhage, contusions, haematomas or effacement of the basal cisterns on CT scanning. The principal reason for considering such monitoring is to help maintain adequate cerebral perfusion (CPP) and oxygenation and thus avoid secondary brain injury. It can be discontinued if the ICP is normal for 24 hours without specific treatment or if the ICP remains greater than 30mm Hg despite all therapy Management of Diabetes Insipidus and Electrolyte Abnormalities Disturbances in electrolyte balance may interfere with cell function and should be avoided. Hyperglycaemia is harmful through its effect on cellular metabolism, so the blood glucose level should be kept at 6-8 mmol/ using insulin as required. The usual precautions on excessively rapid manipulations of the serum sodium should be observed. Diabetes insipidus is a recognised complication of TBI. If it is not treated there is a risk of hypovolaemia and cerebral sinus thrombosis. However, too early or excessive treatment may cause water overload, leading to worse oedema and consequent organ dysfunction. The diagnostic criteria for DI are excessive 38

39 urine output (> 300 ml/hr for 2 hours), rising serum sodium (> 150 mmol/l), plasma osmolarity > 300, and urine SG < 1005 and osmolarity < 300. The treatment of DI consists of 1 ug IV of DDAVP, repeating as necessary every few hours. More treatment doses or an infusion may avoid excessive swings in urine output. The infusion should be 4mcg DDAVP in 50mls run at 1-4 ml/hr to bring the urine output down to 100 ml/hr. The circulating volume can be maintained with non-sodium containing fluids, e.g., 5% dextrose, taking care to control the blood sugar. Inappropriate ADH secretion causes blood dilution due to excess water retention. It leads to a low serum sodium and osmolarity, positive fluid balance, normal 24-hour urinary sodium and raised urine osmolarity. It is treated by fluid restriction, that is, litres per 24 hours. Cerebral salt wasting is due to excessive natriuresis. It causes a low serum sodium and low-normal serum osmolarity and can be treated with sodium replacement. One needs to be careful not to exceed recommended rates of elevation of serum sodium concentrations (<10 mmol/l/day) because of a risk of central pontine demyelination. 39

40 Section 7 BRAINSTEM DEATH/ORGAN DONATION (ADULT ICU PATIENTS) 7.1 Background The idea that a patient could become brainstem dead is artificial and consequent upon the technology available to support ventilation. Brainstem death (BSD) itself was legally defined as death in the USA in A conference of Royal Colleges began work in 1976 and by 1979 brainstem death was defined legally as death in the UK as well. The Royal Colleges made recommendations in response to public concern, which form the framework for the process by which BSD is diagnosed in the UK today. Organ donation from a BSD donor source is impeded by a number of potentially avoidable events: 1. The family is not asked for consent and the organs are wasted. 2. The family is asked but refuses because the request was insensitively made. 3. The family consents but the organs are damaged and rendered untransplantable. 7.2 The Diagnosis of Brainstem Death In the UK this is done following guidelines published by the Royal Colleges. Two experienced doctors (usually the ICU consultant and another experienced doctor > 5 years post full registration) examine the patient together or separately on two occasions. The time of death is the time of completion of the first set of tests. The second set is advisory, and done to reassure all concerned. The second set of tests can be done immediately following the first set but is generally done after an hour or so Preconditions The examining doctors must confirm the cause of brainstem death as a known diagnosis of irreversible coma. The temperature of the patient at the time of testing must be normal (37º C /- 1º C). There must be no major metabolic or endocrine problem, although hypernatraemia to a level of 165 mmols is usually accepted. The effects of sedative and neuromuscular blocking must have worn off. The effect of recreational drugs or long term sedative prescriptions must also be considered. A sensible approach would be to allow a period of 12 hours to elapse after any sedation has been stopped, or longer if the patient has renal or hepatic impairment. Some drugs can be checked by plasma levels via other laboratories, i.e., barbiturates at Sheffield Cranial Nerve Testing (done aseptically in potential donor) Pupillary reflex Corneal reflex Vestibulo-ocular reflex Cough and gag reflex Grimacing/movement in the distribution of the cranial nerves in response to a painful stimulus delivered in the distribution of the 5 th cranial nerve, not peripherally i.e., supra-orbital nerve compression or irritation of the nasal mucosa 40

41 7.2.4 Testing the Sensitivity of the Brainstem to Carbon Dioxide Disconnect ventilator, ensure oxygenation with tracheal catheter, allow hypercapnia > 6.7 kpa. Look for spontaneous breathing effort. If disconnection not possible use ventilator tubing dead space to force rebreathing on 100% oxygen Suitable Donors Age 0-75 No systemic untreated sepsis No malignancy (rarely CNS only) No known HIV infection Although these are recommendations, each case is considered separately and age greater than 75, hepatitis B & C infections may still be appropriate. Suitability for donation can be discussed directly with the donor coordinators who are based at the Manchester Royal Infirmary ( ). They coordinate the procurement of organs within the region. They have an educating role and liaise between families or donors and recipients if required. They are skilled counsellors and have a wealth of experience and knowledge The Family The emotional state, cooperation and consent from the family are very variable. Often they have some idea that an approach will be made regarding donation. This should be done at a second interview, ideally after the news about the patient s brainstem death. The family may ask nursing staff directly. Sometimes it helps the family to see a set of BSD tests so that they take in the irreversible nature of what has happened. In all cases there is shock, disbelief, and sometimes anger and guilt. The family should be asked for consent in all cases of BSD where the patient is suitable. Once the family have consented to donation the process of optimisation of organs can start. This can be discussed sensitively with the family and described as part of the process of organ procurement. The donor coordinator should be involved from this point or before and can provide advice and guidance. 7.3 Optimisation of Organ Function It is the function of the Intensive Care Unit to reverse and prevent organ dysfunction. This is still the case after brainstem death, though it is a unique situation that demands tact and careful consideration of the family and the wishes of the deceased. In order to preserve the function of organs which would deteriorate steadily following BSD, the following steps are suggested: Ensure normovolaemia: insert CVP, arterial line and consider PA catheter, especially where there may be cardiac involvement, e.g., thoracic trauma and in older patients with a history of IHD. Check blood and urine for osmolarity. If the patient has diabetes insipidus start DDAVP 4 mcg in 50 ml at 2 ml/hr. Treat hypokalaemia and follow urine output with 5% dextrose if Na > 140. If the patient is hypotensive despite normovolaemia, commence a T3 infusion of 40 mcg in 50 ml, namely at 10 ml/hr after a 10 ml bolus. Give g of methylprednisolone. Wean patient off inotropes if possible, as they deplete intramyocardial ATP stores. 41

42 Add PEEP (unless contraindicated) if not already on, in order to promote lung expansion. Keep lungs toileted aseptically. Give broad spectrum antibiotics if WCC high and sputum looks coloured. Reduce FiO2 to minimum to keep well oxygenated. Dopamine does not improve renal function and has no place in this scheme. Adequate perfusion of the kidneys follows when normovolaemia is attained. Most patients have a good cardiac output. Avoid hypervolaemia because it might lead to pulmonary oedema. If the patient may be a lung donor IV fluids are best titrated with a PA catheter. The haematocrit should be kept > 30% with a blood transfusion if necessary, but contact the donor coordinators before doing this. 42

43 Section 8 REHABILITATION FOLLOWING TBI 8.1 Introduction The need for co-ordinated rehabilitation services following TBI is recognised. The length of hospital stay for those with moderate and severe injuries is reduced by approximately 30% and the re-acquisition of personal independence increases with specialised inpatient rehabilitation programmes Specific recommendations have been made in the last few years with regard to access to, and provision of, specialised rehabilitation services for people following TBI by the British Society of Rehabilitation Medicine 12, the Royal College of Surgeons 3, the Parliamentary Select Committee on Health 13, the Department of Health 41 and the Royal College of Physicians 87. All of these documents stress the need for access to specialist rehabilitation services from the early stages following acute brain injury through to community reintegration, with some individuals requiring lifelong specialist support The organisation and provision of specialised rehabilitation services for people with neurological impairments following TBI are no different to those for people with similar impairments due to other causes of acquired brain injury such as intracerebral haemorrhage, cerebral anoxia or cerebral infection. The recommendations for the rehabilitation of people after TBI are therefore applicable to all people with acquired brain injuries The rehabilitation of such patients is a multidisciplinary and specialised process, and should start early so as to minimise the development of physical and behavioural complications. While the majority of head-injured patients do not require a formal rehabilitation programme, there should be a structure to identify their rehabilitative needs, as even people with less severe injuries can have long-lasting symptoms that require treatment 5, The Greater Manchester Model for Neurological Rehabilitation This encompasses the following principles for the provision of a comprehensive, coordinated and integrated service across Greater Manchester: Neurological rehabilitation should start in the acute setting, followed by intermediate rehabilitation (in-patient specialised neurological rehabilitation) and/or community-based local rehabilitation, dependent upon the patient s individual needs. The three levels of service provision are equally important and none can be effective without the other two. Deficiencies in any of them will adversely affect functioning at the other levels. There must be equity of access to neurological rehabilitation for all residents The pathways for brain injury rehabilitation described in this document have been developed by the Greater Manchester Neuro-Rehabilitation Design Group and have been endorsed by commissioners for health care. They are compatible with national guidance on the organisation and delivery of rehabilitation services, including those encompassed in the National Framework for Long-term Conditions 88. All clinical guidelines are evidence based and will be subject to audit and review. 43

44 8.3 Rehabilitation in Acute Care Rehabilitation should start as soon as possible after brain injury. Patients with TBI may have other injuries adding to the complexity of their care. Rehabilitation interventions at this stage should focus on the prevention of complications and avoidance of impairments, e.g., chest care and dysphagia management, prevention of limb contractures, maintenance of tissue viability and minimisation of behavioural difficulties The delivery of acute rehabilitation is dependent upon where the patient is admitted following the acute incident, and will be determined by the protocols described in previous sections of this document. Patients receiving their acute care in the Neurosciences Centre will be transferred to the most appropriate rehabilitation service that meets their needs, which may be the Acute Rehabilitation Unit within the Neurosciences Centre The quality of care, including rehabilitation, should not be compromised by where the patient is managed. For hospitals outside the Neurosciences Centre it is recommended that specified consultants take on this responsibility, such that they and their clinical teams develop the necessary skills. Several models of service delivery could be considered to meet the local need, for example: An acute brain injury service incorporating all acquired brain injury (e.g., TBI, anoxic brain injury, complex intracerebral haemorrhage, encephalitis), which might also include acute stroke. A clinical area with a clinical team specialising in TBI management. Peripatetic teams of specialist nurses and therapists. An acute liaison service from the relevant Intermediate Rehabilitation Unit (IRU) Whatever the local service model, there should be close working links with the appropriate IRU for specialist advice and to ensure timely transfer to a rehabilitation bed. All hospitals in Greater Manchester should have ready access to specialist medical advice from a Consultant in Rehabilitation Medicine. Patients should be jointly managed by a dedicated local Consultant and a Consultant in Rehabilitation Medicine. 8.4 Intermediate Neurological Rehabilitation There are four Intermediate Rehabilitation Units (IRUs) in Greater Manchester providing specialised in-patient and out-patient services for people with neurological impairments. Which IRU a patient is admitted to is determined by where they live. Equity of access and equity of provision are basic principles of the neurological rehabilitation service The diagram on page 46 gives details of which IRU should be contacted. For patients who live outside Greater Manchester, or are registered with a Primary Care Trust outside the contracted areas, advice will be given regarding their rehabilitation needs and possible placement Involvement of the IRU team at an early stage following the acute incident will ensure appropriate rehabilitation intervention to minimise impairments and complications. Timely transfer to an appropriate in-patient or out-patient rehabilitation service can then be arranged Brain injury rehabilitation at this stage focuses on maximising activity (facilitating independence in personal and domestic daily living tasks, improving communication and enhancing cognitive abilities). This is a complex, specialised process requiring a skilled interdisciplinary team 41. The IRUs should also provide specialist outreach services, namely out-patient clinics, specialist liaison nurses and community based cognitive rehabilitation. These services are not yet fully available throughout the conurbation. 44

45 The guidelines set out in this chapter have been developed by, or in association with, the Greater Manchester Neurorehabilitation Clinical Standards Group. They are also applicable to patients with other causes of neurological impairment. The principles of management apply wherever the patient is situated, i.e., in an acute setting (intensive care unit, neurosurgical ward, any acute hospital bed) or in a rehabilitation service. These guidelines are subject to audit and review. 45

46 Rehabilitation Pathway following TBI Acute admission to the Neuroscience Centre Acute admission outside Neuroscience Centre In-patient rehabilitation not necessary Acute Rehabilitation Unit, Neuroscience Centre* Requires rehabilitation but not in an acute setting Discharge home or to local hospital bed with appropriate follow-up Intermediate Rehabilitation Unit (IRU) Neurorehabilitation Unit, Manchester Royal Infirmary, for residents of Manchester, Salford & Trafford Devonshire Centre for Neurorehabilitation, Stockport, for residents of Stockport, Tameside / Glossop & some Manchester residents Floyd Unit for Neurological Rehabilitation, Rochdale, for residents of Rochdale, Bury & Oldham Leigh Infirmary for residents of Wigan and Bolton Discharge with the following, where appropriate: Community rehabilitation, including cognitive rehabilitation Specialist nurse involvement Rehabilitation Medicine follow-up Neuropsychology follow-up Community / OP therapy Social support, including respite Specialist health support, including respite Appropriate residential placement * If there is a shortage of acute Neuroscience beds, it may be necessary to transfer patient to an appropriate DGH bed 46

47 8.5 Assessment and Management of Swallowing Problems Dysphagia is common following severe TBI and is a significant cause of morbidity, with a high risk of aspiration pneumonia. All such patients should have an assessment of swallowing before they are given oral fluids and/or nutrition. The referral mechanism will vary between hospitals. Some have a dysphagia link nurse who undertakes a formal swallowing assessment. If there is any suspicion of dysphagia it is advisable to continue with enteral nutrition and hydration until the patient is examined by an appropriately experienced speech and language therapist. Guidelines for Management of Dysphagia in Adults Referral to Speech & Language therapy for swallowing assessment Clinical assessment with or without mealtime observation DYSPHAGIC NOT DYSPHAGIC Objective assessment, eg, videofluoroscopy Intervention Nil by mouth Dietary modifications Direct/indirect treatment Referral to other professionals Discharge Review and repeat bedside and/or objective assessment as required Dysphagia resolved or not requiring intervention 47

48 8.5.2 For patients with a tracheostomy, the following must also be taken into consideration 64,65. Increased risk of aspiration Reduced movement of the larynx during swallowing Partial obstruction of the oesophagus due to an inflated cuff Less effective swallow due to altered subglottic pressure Compounding of existing dysphagia from underlying medical conditions Reduced airway protection Assessment for oral intake is not appropriate if the patient is unable to tolerate cuff deflation 66,67. Referral may still be appropriate to promote pre-requisite skills for swallowing and communication. 8.6 Management of Spasticity and Prevention of Contractures In the early stages following TBI muscle tone may be reduced. It is essential at this stage to prevent the development of contractures involving soft tissues and joints. Paralysis will result in some muscles being immobilised in a shortened position, which may be the first generator of spasticity. It is also important to prevent compression neuropathies, most commonly at the elbow (ulnar nerve) and knee (common peroneal nerve). Involvement of neurophysiotherapists and neuro-occupational therapists in the early stages following TBI is crucial if such complications are to be avoided. Splinting in these situations requires skill to avoid compromising tissue viability and causing pressure sores Spasticity tends to occur from days to months following TBI. The severity of spasticity is variable, depending on the site of damage within the CNS and the presence or absence of aggravating conditions such as urinary tract infection, renal tract stones, faecal impaction or pressure sores 69. Spasticity is also influenced by position. For example, lying flat can increase extensor tone in the trunk and legs with an increase in flexor tone in the arms Spasticity causes pain, deformity and impaired function. If left untreated abnormal limb and truncal postures develop, preventing muscle stretching and perpetuating further deformity. The management of spasticity requires a skilled multidisciplinary team and clear objective and measurable goals of treatment should be agreed. Treatment may involve more than one modality 70, as outlined in the guidelines on the following page. 8.7 Prevention and Treatment of Heterotopic Ossification Heterotopic ossification (HO) is the formation of bone outside the skeleton, i.e., in tissues which do not usually ossify. Patients with TBI are susceptible to the formation of HO, which can severely affect function by restricting movement and resulting in fixed joints. The incidence of HO following head injury is 10 to 20% 71,72. In those with severe TBI, with or without multiple trauma, it may reach 40% The development of mature HO reflects suboptimal care. Prevention is the main line of management, namely physiotherapy with passive movements, early treatment of pain and spasticity, and prevention and management of pressure sores. Patients with severe spasticity, immobility and previous HO are at greatest risk 74. Guidelines for the diagnosis and management of HO are given on page

49 Management of spasticity in patients with TBI Treat spasticity if: It is causing pain This will prevent or reduce contractures It is adversely affecting function It is compromising safety Management principles Treatment is essentially physical A multidisciplinary team approach is essential Systemic pharmacological treatments are not a substitute for physical measures Where possible eliminate stimuli which can exacerbate spasticity, eg, constipation, infection, skin irritation (tight catheter leg bag, ill-fitting orthosis), pain, pressure sores Pharmacological treatment agreed to be necessary Is the spasticity focal or generalised? Generalised/multi-segmental Refer back to management principles Systemic antispasticity agents have limited efficacy in spasticity of cerebral origin Baclofen, Dantrolene & Tizanidine all have potential adverse cognitive effects and lower seizure threshold Focal Spasticity Consider physical treatments alone or in conjunction with local Botulinum toxin injections It may be necessary to treat a focal problem within multisegmental spasticity 49

50 Management of Heterotopic Ossification in TBI Prevention Early gentle physiotherapy Treat pain, spasticity and pressure sores Clinical examination (range of movement, pain, tenderness, swelling) Biochemistry (U/E, LFT, Ca, PO4, Alk Phos) ESR Suspicion Repeat clinical examination Biochemistry XR and U/S (depending upon local facilities and experience) Clinically positive High Alk Phos Diagnostic XR and/or U/S Clinically positive High Alk Phos Non-diagnostic XR and/or U/S Clinically positive Normal Alk Phos Non-diagnostic XR and/or U/S Clinically positive (severely reduced ROM or ankylosis) Normal Alk Phos Diagnostic XR Medical Treatment Disodium etidronate oral/enteral 20 mg/kg/d (max. 1.2 g/d) for 6 months Gentle physio Follow-up Biochem monthly XR 3 monthly Three phase bone scan Repeat clinical examination and biochem weekly XR or U/S after one week ve -ve -ve ve Mature HO? Significantly affects patient s function/ quality of life? NO, then continue to observe YES Consider other diagnosis Treat Bone scan to establish maturity Surgical excision may be possible Post-operative prevention: Radiotherapy and/or oral etidronate for 3 months physiotherapy Continue Rehabilitation 50

51 8.8 Assessment and Management of Pain Accurate diagnosis of the causes of pain following TBI is necessary in order to give appropriate treatment. Pain can exacerbate spasticity and worsen agitation. It may be caused by the direct effects of the injury (e.g., associated orthopaedic trauma), the neurological impairment (e.g., spasticity or neurogenic pain) or an indirect effect (e.g., sympathetic dystrophy, development of HO, urinary retention or constipation) Adequate pain control is essential to maximise participation in rehabilitation, prevent physical complications such as contractures and minimise behavioural difficulties. The treatment of pain will be determined by its cause and severity. Severe pain causing distress will require morphine, less severe pain can be managed using simple analgesics such as paracetamol or a non-steroidal anti-inflammatory agent such as diclofenac, if there are no contraindications to NSAIDs such as the use of anticoagulants Neurogenic pain can follow a CNS insult or peripheral nerve lesions from compression or trauma; critical illness neuropathy can also be a factor. The choice of treatment for neurogenic pain will be determined by a number of factors. Amitriptyline and nortriptyline lower the seizure threshold, so patients with epilepsy or behavioural difficulties may be better treated with carbamazepine. On the other hand, carbamazepine can cause drowsiness and adversely affect cognitive function. If the guidelines suggested below are ineffective, advice should be sought from the neurorehabilitation or specialist pain services. Guidelines for the Management of Neurogenic Pain Amitriptyline 10 mg at night Increase in 10 mg increments every 3 rd night to maximum of 150 mg OR Nortriptyline, which may cause less sedation No benefit or adverse effects Change to Partial effect Add Gabapentin 300 mg bd to max 600 mg qds. OR Carbamazepine 100 mg bd Increase according to response up to about 800 mg a day 51

52 8.9 Patients Exhibiting Behaviours which Challenge Services The IRUs should be able to manage patients with challenging behaviour. Examples include agitation, confusion and wandering. Such patients tend to require a high level of supervision (often on a 1:1 basis) in order to maintain their safety. The following section gives specific guidance on the assessment and management of such patients, which applies wherever the patient is being cared for Agitated patients should be given priority for transfer to a rehabilitation bed. For patients on a neurosurgical ward, this will be to the Acute Rehabilitation Unit in the Neurosciences Centre. Those being cared for outside the neurosurgical envelope will be given priority for transfer to the corresponding IRU. The transfer of patients with behavioural difficulties to an IRU bed will depend on adequate staffing levels and the clinical needs of other patients. Agreement must be reached with local commissioners of health care as to the course of action to be taken if an appropriate bed is not available on the IRU. This may involve an independent provider of brain injury rehabilitation, though preferably resources should be made available to develop appropriate facilities within the NHS It may not be possible to admit patients to an IRU bed if their behaviour is so severely disturbed that they pose a risk to other patients or staff. In this situation decisions regarding the best placement should be made by the local commissioner for health care in collaboration with the IRU team, the Consultant in Rehabilitation Medicine and a Consultant Neuropsychologist. Relevant members of the IRU and community rehabilitation teams must be involved in the monitoring of any such specialist placement to ensure its effectiveness and continuing need. They must also be involved in the discharge planning process to facilitate return to local services as soon as clinically appropriate. This will be facilitated if Cognitive Rehabilitation services are developed The Management of Agitation and Confusion following Traumatic Brain Injury The literature suggests that 33-50% of people emerging from coma due to TBI experience a period of confusion, with or without agitation: these behaviours can be disruptive and potentially unsafe 75. During this time the patient is in Post-Traumatic Amnesia. PTA and confusional states in the early stages following acute brain injury are a form of delirium 26. The duration of PTA includes the period of coma and extends until the patient s memory for ongoing events becomes reliable, consistent and accurate. This period may also be associated with disorientation, agitation and restlessness 26. During PTA the patient may exhibit the following problems: Cognitive features Behavioural features Disorientation in time and place Confused speech content Impaired memory Poor concentration, easily distracted Slow information processing Easily overloaded Perseveration Restlessness Sleep disturbance Agitation / irritation Aggression verbal or physical Easily fatigued Wandering and absconding Sexually inappropriate Since many factors can contribute to confusion, each patient must be assessed individually. An accurate diagnosis is essential before implementing a management strategy. A diagnosis of PTA can only be made when other causes of confusion and agitation have been treated or excluded. In patients whose agitation is so severe that clinical assessment is not possible, it may be necessary to treat the agitation to facilitate clinical assessment Behavioural and environmental management is crucial. It should be implemented if possible before considering medication, which should not be used as an alternative to modification of the environment or behavioural interventions. Patients should be transferred as soon as possible to 52

53 the most appropriate neurorehabilitation service. If medication were to be used as a substitute for behavioural management it could be viewed as chemical restraint If a decision is made to use medication, this must be a collaborative decision involving relevant team members and there must be defined goals of treatment. Any prescribed medication should be reviewed daily as the clinical situation may change at different rates in different patients. The primary aim of drugs in this situation is to reduce agitation (i.e., the treatment is symptomatic and not curative) when it is potentially harmful to the patient. Major tranquillisers / antipsychotic agents should be avoided. They have potential serious adverse effects and can cause an increase in confusion, which may in turn exacerbate agitation 77. Benzodiazepines are the preferred pharmacological agent for short-term use. Any other drugs should only be prescribed following specialist assessment, ideally involving consultants in neurorehabilitation or neuropsychiatry. It is acknowledged that this may not be possible in all hospitals in Greater Manchester, in which case they should develop links with the IRU responsible for providing services to their population. The following general principles apply to pharmacological management. Avoid major tranquillisers such as haloperidol and chlorpromazine because they may adversely affect neuronal recovery, reduce seizure threshold and cause an extrapyramidal syndrome or, rarely, a neuroleptic malignant syndrome 77 For reduction of agitation in the short term a benzodiazepine is preferred, but be aware of potential respiratory depression and occasional paradoxical increase in agitation 80 If Benzodiazepines are ineffective or contra-indicated, consider valproate semisodium (this should be used on specialist advice only) Carbamazepine /- Propranolol useful in some situations on specialist advice (neurorehabilitation or neuropsychiatry) Environmental and behavioural interventions aim to place minimum demands on the patient s impaired cognitive function, thus limiting the risk of harm to the patient and other consequences of disturbed conduct. Awareness of potential problem behaviours and early intervention may prevent the development of more intractable problems later. Environmental and behavioural interventions should be developed following a comprehensive assessment by a clinical psychologist. The assessment should follow the principles of functional analysis and ascertain possible precipitating factors for behavioural disturbance as well as maintaining factors. Areas to explore include: 1. The physical environment (lighting, noise, heat) 2. The nature of social interactions (communication style, ward staff and visitors) 3. The degree of stimulation (excess or deficiency) 4. Available rewards and punishers within the person s environment 5. Cognitive factors (e.g., perception, attention and memory) Careful assessment of such factors should lead to an intervention plan based on environmental modification, skill training and behavioural modification strategies 27. Clinical neuropsychological intervention may include recommendations regarding environmental changes, communication strategies, the structuring of therapeutic activities, managing visitors, staffing issues and formal behavioural modification techniques using carefully selected rewards and punishers. In the interim, before formal assessment by a clinical neuropsychologist is undertaken, the following general environmental guidelines may be considered for the patient displaying confused and/or agitated behaviour following TBI. 53

54 General Guidelines for Environmental Management of Patients with Confusion and/or Agitation following TBI 78 Move the patient to a side room or quiet part of the ward to minimise excessive stimulation The ward environment should include reminders of location and time to aid orientation such as signs and a clock All staff should verbally orientate patients to time and place and introduce themselves and their purpose at every intervention Patients who wander should be allowed to do so with an appropriate level of supervision, which may require 1:1 specialling in some situations The patient should have a structured day with timetabled events and rest periods Patients who are restless in bed may be nursed on a mattress on the floor Staff may use distraction and redirection techniques to help the person progress from their behavioural disturbance Involvement of a neuropsychologist is essential for the clinical management of patients in PTA. Comprehensive assessment is required to guide management. Outside the neurorehabilitation environment the neuropsychologist can give advice regarding specific environmental and behavioural interventions. Ideally all such patients should be transferred to an appropriate rehabilitation service Management of Patients who may try to Abscond This is a particularly difficult situation in which health professionals actions should be based upon consideration of the patient s capacity to refuse treatment, risk to the patient and others from self discharge and the Human Rights Act. Practitioners should adhere to their local Trust policies relating to patients who try to abscond; this may require involvement of Trust legal departments particularly in situations where the Human Rights and Mental Health Acts are pertinent. 54

55 Management of Patients with Post-Acute Cognitive, Behavioural and Emotional Disturbance following TBI Causes of confusion or agitation Patient with TBI becomes confused or agitated Clinical assessment Medical history and examination Obtain information from nurses & therapists regarding behaviour over time Secondary complication of the TBI e.g., obstructive hydrocephalus, CNS infection Seizure disorder i.e., epilepsy (may be partial seizures) Infection outside the CNS e.g., respiratory Hypoxia due to respiratory or cardiac causes Metabolic check glucose, biochemistry Fat embolism if polytrauma Adverse effects of medication Withdrawal from alcohol or drugs Due to primary TBI Due to a complication of TBI but awaiting treatment or response to it Due to a complication of the TBI requiring immediate intervention Behavioural & environmental management Pharmacological management may be complementary to the above if unsuccessful alone, or if the above cannot be implemented immediately, and There is a risk of harm to the patient or others A collaborative decision has been made to use medication Establish goals of treatment and method of monitoring response Implement appropriate treatment Clinical neuropsychology to assess and plan intervention Implement appropriate general guidelines for environmental management of patients with confusion and/or agitation If immediate response necessary, lorazepam 2-4 mg orally or IM OR Intranasal midazolam 5-10 mg For longer term treatment see advice on page 57 55

56 Section 9 FOLLOW-UP 9.1 Introduction It is evidently important to impart to patients and relatives information about possible sequelae of the head injury and advice on return to driving, work or sport. Patients who have PTA of over an hour, a fractured skull, or neuropsychological or neurological symptoms at discharge from hospital are more likely to have residual problems 83. Follow-up ensures that problems are picked up and that contact has been made with the relevant services 84. The more severe the head injury, the more useful an interdisciplinary approach to the patient s problems is likely to be, but even moderately and mildly head-injured patients may benefit. Persistent cognitive and emotional problems are found in approximately 10% of people with a mild TBI and 40% of those with a moderate TBI. 9.2 Specialist Cognitive Rehabilitation Teams Persistent cognitive, emotional and behavioural problems are found in a substantial proportion of patients with TBI 12. For the majority of patients they present the main obstacle to a return to independent community-based living. Since the early 1980s, scientific evaluations of outcome have repeatedly identified and confirmed that they constitute the majority of long-term problems. The ongoing strain experienced by patients and carers and the subsequent cost to the healthcare system are very high The Greater Manchester Neurorehabilitation Service Design Group recommended the provision of specialist Cognitive Rehabilitation Services associated with each of the four IRUs. Their aim is to provide outpatient, community-based rehabilitation for patients with cognitive and behavioural problems that interfere significantly with aspects of everyday living 85. Cognitive Rehabilitation Services should be an outreach of the IRU and should be based at, or close to, each IRU. Once developed, each team will provide the following: 1) Group programmes They consist of part-time, time-limited programmes of structured cognitive rehabilitation aimed at improving attention, memory, problem solving, communication and social skills. They will also include cognitive-behavioural treatments for anger management and emotional difficulties. 2) Individual outpatient service (i) (ii) Some patients with severe problems will be unable to meet the demands of the cognitive rehabilitation programme without prior intervention, or may require additional individual help. Specialist neuropsychological and therapy assessment for those patients who have not previously had access to them. Some patients may need specific interventions to enable optimum participation in cognitive rehabilitation. 3) Advice and support service to the community rehabilitation team This is for patients whose cognitive and behavioural problems interfere with their ongoing management and community-based rehabilitation. 56

57 9.3 Services for People with Mild and Moderate TBI There is increasing evidence that significant numbers of people with mild head injuries are unable to maintain their pre-accident performance level 86. Many patients experience a post-concussional syndrome after TBI. This may consist of headache, dizziness, noise intolerance, impaired concentration, fatigability, depression, irritability, sleep disturbance, memory difficulties, loss of sexual drive, low tolerance to alcohol and general restlessness. In the majority of people these symptoms will pass within 1-3 months, but in some they continue for longer Patients should receive information regarding the type, extent and duration of symptoms that can be expected, preferably in the form of a leaflet or booklet that can be taken away. Counselling is also needed with regard to work, which may have to be on a part-time basis if post-traumatic symptoms persist. If they are present after three months a formal neuropsychological assessment is necessary to document the symptoms and help the person to develop coping strategies. All patients admitted to hospital with TBI, however briefly, should return to a head injury clinic or other suitable setting around three months after the event. 57

58 Service Model for Mild and Moderate Head Injury Assessment in A&E Department Admit for treatment Discharge with head injury advice Opt-in service 1-week follow-up from Head Injury Specialist Nurse. Specific information given re recovery, return to work etc. 3-month OP follow-up by Head Injury Specialist Nurse Structured interview will determine discharge or referral to specialist services Discharge Neuropsychology Neurorehabilitation Other therapists e.g., OT, speech therapy Cognitive rehabilitation / pre-vocational / vocational training Early follow-up for patients with moderate TBI This should be provided by a specialist head injury nurse (SpN) or co-ordinator, who identifies all patients admitted to each DGH with moderate TBI. Patients not transferred to the IRU should be reviewed (via a home visit) within one week of discharge. At this point they should receive written and verbal information on what to expect during recovery and advice on the resumption of daily activities Follow-up for patients with mild TBI Patients admitted to hospital should receive the same follow-up service as those with moderate TBI. Patients discharged after treatment in the A&E Department will receive a head injury 58

59 information leaflet, and should also be given a telephone contact number for the SpN. Patients should have direct access for up to 3 months following TBI, after which referral to the service will be via the general practitioner Three month follow-up for patients with moderate TBI Review should be available by the SpN or head injury co-ordinator in an outpatient clinic. On the basis of a structured clinical interview and responses on a set of questionnaires, the SpN will be able to recommend discharge or referral to clinical neuropsychology, rehabilitation medicine or other therapists. Services located in the community or at the relevant IRU could be accessed. The decision whether a referral is made to the community or IRU will be made on the basis of locally defined criteria. Patients who have persistent cognitive problems should be referred for outpatient/communitybased cognitive rehabilitation and/or a pre-vocational training programme. They should be developed and provided as an outreach service from the IRUs to their catchment population. Some patients may be more appropriately managed by outpatient or community based neuropsychology services. The full range of services should be available to meet the needs of individual patients. 9.4 Community Rehabilitation and Support The majority of people following TBI will return to their local community. A few will be so severely physically and/or cognitively impaired that they will require long-term residential care in a nursing home or specialist residential facility. Those remaining at home with their families may need access to respite care in specialist or non-specialist environments The aim of community-based rehabilitation is to maximise participation in society. This is dependent on the severity of the residual impairments and on local facilities. Patients may need access to a variety of different services, including out-patient and domiciliary therapy services, community rehabilitation concentrating on independence within the community (including work and leisure) and medical review Some services within the community may need to be commissioned collaboratively with, or solely by, the Social Services. Involvement of non-statutory organisations that include service users (e.g., Headway, BASIC, Greater Manchester Neuro-alliance) in the planning and provision of services in the community is to be commended. 59

60 Appendix 1 AUDIT OF TBI MANAGEMENT This section reflects the activity of the Greater Manchester TBI Audit Group since the publication of the first framework in A1.1 Updating the framework document The document has been updated in response to comments from stakeholders in the Greater Manchester TBI audit group meetings. This includes the change in the assessment of headinjured patients in Emergency Departments recommended by NICE. CT scan rather than skull x- ray will be the major imaging mode of investigation. Literature reviews have been carried out by Richard Protheroe, and the intensive care and brain stem death sections have been updated. The neurosurgical care section has also been updated. A1.2 Intensive Care of patients with Severe TBI in Greater Manchester using TARN data GM TARN data from were reviewed to look at the outcome and process of care for all trauma cases in general and more specifically for cases with severe head injury. A Outcome The observed deaths from all causes of trauma in Greater Manchester were 1% greater than those that would be expected. There was a trend to improvement over time. In there were 408 patients with a major head injury (confirmed by CT scanning) admitted to hospitals across Greater Manchester (excluding Hope Hospital) of which only 27% (110) were transferred to the Neurosciences Centre for further care. The national figure is 31%. Severe head injury is defined as a major traumatic brain injury causing coma (GCS <9). There were 236 cases of severe head injury during the study period. First hospital for patients Transferred N Survival % (n) Required neurosurgery Survival excluding neurosurgery GM* No % (40) 5% 34% (36/105) GM* Yes out 61 Not known Not known N/A Hope No 34 50% (17) 29% (10) 43% (10/23) Not known Into Hope 92 67% (59) 62% (57) 74% (26/35) * Greater Manchester but not Hope A further 176 patients with severe head injury were transferred into Greater Manchester hospitals but not Hope during this time (initial hospital uncertain). This was probably to MRI and NMGH when they had on-site neurosurgery. The mortality rate was 15% (12% for the 85 neurosurgical cases and 19% for the non-neurosurgical cases). 60

61 It would be reasonable to compare the outcomes of head-injured patients not requiring neurosurgery that arrived and stayed at Hope (43% survival) and arrived and stayed elsewhere in Greater Manchester (34% survival). These groups were similar in terms of age, injury severity and presenting coma score. It is evident that there was a very significant difference in the survival rates. A1.2.2 Conclusions Over the time period studied about 50% of patients with severe head injury did not receive neurointensive care. Their outcome was worse than those that did. Almost half of the patients with severe TBI who were treated in the Neurosciences Centre survived, whereas only a third of those treated in other intensive care units across the city survived. This disparity is not explicable on the basis of differences in the casemix. Moreover, the improved survival rate is not at the expense of greater disability. There are indications that survivors of severe TBI treated in the Neurosciences Centre have a better functional outcome than those dealt with elsewhere. Given these data, there is an overwhelming case for all patients with severe head injury to be treated in the Neurosciences Centre. A1.2.3 Implications for changes in service From the GM TARN data we believe that there may be a % underestimate in the total number of cases recorded. If all severe head injuries are transferred to Hope, the following assumptions can be made: No. of extra transfers to Hope over 4 years from the current data = 110 or 27 per annum If the data are assumed to be a 66% underestimate = 45 extra cases per annum If the date are assumed to be a 100% underestimate = 54 cases per annum Any costs to be incurred would be offset against 4-8 additional lives saved per annum (mainly young males). The implications are that between 27 and 54 additional cases of severe head injury per year would need treatment in a neuro-intensive care unit. This would result in between 4 and 8 additional survivors per year and, assuming they were young men aged around 20, a total of something between (75-20) x 4 = 200 and (75-20) x 8 = 400 years of life saved per year. The number of additional patients in the Neurosciences Centre would probably be less than 1 per week, but this would have a knock-on effect on all tiers of treatment. The mean length of stay on ICU for patients with primary brain injury Hope is 9 days, while on Neuro HDU it is 4 days. Thereafter patients with TBI stay on the Neurosurgical wards on average for 8-9 days, and ideally on the Acute Neurorehabilitation Unit for days. A1.3 Time to theatre for patients with operable intracranial haematomas A1.3.1 The neurosurgical team collected data on patients admitted to the ITU at Hope with a severe head injury over a 6-month period. Thirty-eight patients were admitted and notes were available on thirty. Their ages range from 16 to 86 years. Fifteen had a neurosurgical operation and nineteen underwent ICP monitoring. There is historical evidence suggesting that outcomes worsen if patients with an EDH undergo surgery at an interval > 2 hours from the time of deterioration or from the time of injury if they never regain consciousness The corresponding figure for acute subdural haematomas is 4 hours. The neurosurgical audit established that the mean delay for extradural haematomas was 5.7 hours (range ), whereas for subdural haematomas it was 5.4 hours. These results are well outside the recommended limits. During the last six months there have been some improvements: delay for patients with SDH 4.6 hours and for EDH 5.1 hours. However, only 30% 61

62 (3/10) SDHs reached theatre within 4 hours of injury and none of the seven patients within EDH reached theatre within 2 hours of deterioration. A1.4 Head injury management in Greater Manchester: performance according to national standards A number of RCS/BOA standards of care are measured by TARN. These standards are outlined in the themed quarterly reports (Head Injuries, Spinal and Abdomen, Thoracic and Orthopaedic). This section relates to the RCS/BOA standards of care under Section 13.2 relating to Major Head Injuries and NICE Head Injury Guidelines. The following section compares GM TARN to the TARN database as a whole over the time period It relates to serious head injuries, i.e., those patients with an Abbreviated Injury Score of >2 to the head (brain injuries on CT, base of skull and compound fractures). It is important to note that not all Greater Manchester hospitals have been submitting data over this time period. A1.4.1 Standard 4 All receiving hospitals must have direct access to 24 hour CT scanning with on-call radiologists. NICE Guideline CT imaging of the head should be performed (that is, imaging carried out and results analysed) within 1 hour of the request having been received by the radiology department in those patients where imaging is requested. ATLS American College of Surgeons Committee on trauma 1997 An emergency CT scan must be obtained as soon as possible, ideally within 30 minutes of injury. Median Time to CT Scan Isolated Head Injuries AIS3 Head Injuries AIS3 with other body regions injured NICE Guideline 1 hr 1 hr Greater Manchester 1 hr 28 mins 1 hr 20 mins TARN Database 1 hr 25 mins 1 hr 20 mins TARN Quickest 43 mins 42 mins TARN Slowest 4 hrs 20 min 5 hrs 45 mins With respect to the median time to CT Scan, Greater Manchester is again generally in line with the national (TARN) picture. However, it falls short of the NICE Guideline recommendations of scanning within 1 hour. 62

63 Greater Manchester TARN Database CT Scan Performed Head Injuries AIS3 with other Isolated Head Injuries AIS3 body regions injured Yes No NR* Yes No NR* % 12.1% 9.5% 74.6% 13% 12.4% % 12.9% 7.3% 72.8% 18.3% 8.9% TARN Range % 2 57% 1 39% 37 99% 6 60% 2 44% A1.4.2 Standard 8 Patients with severe head injuries or focal signs should be transferred to the care of neurosurgery units regardless of whether they need surgical intervention. Transfers of patients with major head injury in Greater Manchester in the period Head Injuries AIS3 with other Isolated Head Injury AIS3 injured body regions Transferred Not Transferred Transferred Not Transferred RCS Standard 8 100% 100% Greater Manchester (excluding Hope) 26.8% 73.2% 27.1% 72.9% TARN Database Non neurosurgical units 33.8% 66.2% 28.5% 71.5% TARN Range 7 88% % 7 75% % From the data in Table 4.3 it appears that Greater Manchester is not able to transfer as many patients as it should. The target is 100% and both Greater Manchester and TARN as a whole are falling significantly below this. Recording of Glasgow Coma Scale on arrival at Hospital for patients with isolated head injuries of AIS3 GCS = 15 GCS < 15 Not Recorded Greater Manchester TARN Database % 58.7% 3.7% % 65.2% 5.9% TARN Range 8 57% 37 98% 1 29% 63

64 Recording of Glasgow Coma Scale on arrival at Hospital for head injured patients with AIS3 and other body regions injured Greater Manchester TARN Database GCS = 15 GCS < 15 Not Recorded % 76.9% 4.5% % 70.7% 6.1% TARN Range 7 54% % 2 35% The recording of GCS in the region is good and slightly better than the TARN average. A1.5 Audit results from the NW A&E consultants group regarding CT scan availability An audit was carried out to establish to what extent radiology departments in Greater Manchester have attempted to meet the recommendations in the NICE guidelines. Three trusts have implemented a 24-hour radiology service that matches the NICE guidelines and one has been able to do so for the daytime. The rest have not made any changes in policy, though it is assumed that internal discussions are taking place. The majority estimated that extra CT head scans would be needed per month in each DGH accepting TBIs if the NICE guidelines were implemented. All the ten hospitals that participated in the audit had CT scanning available 24 hours a day. Nine of the ten hospitals required either a middle grade or a consultant to request the scan. In only one hospital was a radiographer on site and in none of the hospitals was a radiologist on site. Most units anticipated that the implementation of NICE could result in an extra 2 scans per day. The majority of hospitals were unsure as to whether they would be able to implement NICE guidelines due to the limited radiology service available, particularly out of hours. Two hospitals were hoping to implement slightly modified guidelines. One hospital had initially decided not to use the guidelines. A1.6 Neurorehabilitation Audits Although there is a neurorehabilitation network through the IRUs and community based services, it is acknowledged that a number of patients are not referred who potentially would benefit from neurorehabilitation. There is a need for a head injury ICU admission to trigger a neurorehabilitation referral. However, this might raise difficulties because of the lack of capacity and service provision in some areas. Recent neurorehabilitation audits have highlighted the following problems: Long lengths of stay (more than the desired 4 weeks) for TBI patients in the acute neurorehabilitation unit at Hope due to lack of access to intermediate rehabilitation units, especially the Floyd Unit and MRI. The planned length of stay for patients is 28 days. In 2004 the average length of stay for those from the Floyd Unit s catchment area was >60 days, and for MRI >40 days (not including several patients not yet discharged at the end of 2004 whose eventual length of stay was 6 to 12 months). Patients (55%) are thus often discharged home directly from the acute neurorehabilitation ward. This is against current guidelines but occurs because the average wait for a bed in IRUs is excessive. It had been anticipated that only 25% of patients would be discharged directly home. The service was not designed for this, with the consequence that some patients who would benefit from active rehabilitation are not having access to it. 64

65 The IRUs have beds blocked by patients who could be managed at home, if adequate community neurorehabilitation and social service packages were available. This was identified in a 12-month prospective audit on the Floyd Unit; issues are similar for North and South Manchester residents at MRI. The above audit also identified major discharge delays, such that with 30 to 50% of patients on the Floyd Unit were inappropriately placed in an inpatient rehabilitation environment at any one time. The reasons for this were found to be multiple, but the process of securing funding for continuing care and the complexities of arranging appropriate social care packages were the main reasons. A service mapping exercise (an audit of community rehabilitation services against the British Society of Rehabilitation Medicine standards for community rehabilitation) has revealed continuing inequities in community service provision in several areas of Greater Manchester, these being most evident in the catchment areas of the Floyd Unit and MRI (for Manchester residents). The Greater Manchester Neurorehabilitation Network is involved in a number of audit projects, which are at various stages within the audit cycle. Those of particular relevance to TBI are: The management of neurogenic dysphagia. This is completing its second cycle following implementation of recommendations from the first audit cycle, including specific training for speech and language therapists on various specialist aspects of dysphagia management. The management of focal spasticity first cycle completed. Audit of the National Clinical Guidelines for Rehabilitation following Acquired Brain Injury (Royal College of Physicians). Funding has been secured for this project, which will include service mapping with regards to provision for people with mild and moderate head injury. A1.7 Summary A number of problems have been identified: Availability and timeliness of CT brain scan for patients with head injury in all receiving Greater Manchester Emergency Departments Availability of Neurosciences ICU beds to enable transfer of all patients with severe head injury to Hope Timeliness of transfer of accepted patients to Hope Access to comprehensive neurorehabilitation services The TBI Audit Group plans to take forward major initiatives that will address the problems listed above. Some changes have already been implemented. For example, almost all recent referrals to Hope of patients with TBI and a Glasgow Coma Score of <8 have been found a neuro-icu bed by the accepting neurosurgical registrar, even if this bed was in another Neuroscience Unit such as Walton or Preston. Further planned initiatives include: 1. To increase the number of neuro-critical care beds at Hope; this is being taken forward with commissioners. 2. An initiative to enable consultant radiologists throughout the city to view CT scans on notebook computers via a web-based link. 65

66 3. A managed clinical network for neurosciences in Greater Manchester. 4. To improve participation and data collection for TARN throughout Greater Manchester. 5. Promote the availability of neuro-rehabilitation for patients with head injury. The GM TBI Audit Group will continue to monitor the situation through the data sources already exploited in order that the audit loop can be closed. 66

67 Appendix 2 67