Management of Severe Traumatic Brain Injury
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2 Management of Severe Traumatic Brain Injury
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4 Terje Sundstrøm Per-Olof Grände Niels Juul Carsten Kock-Jensen Bertil Romner Knut Wester Editors Management of Severe Traumatic Brain Injury Evidence, Tricks and Pitfalls
5 Editors Terje Sundstrøm, M.D. Haukeland University Hospital Bergen Norway Department of Surgical Sciences and Department of Biomedicine University of Bergen Bergen Norway Per-Olof Grände, M.D., Ph.D. Department of Anaesthesia and Intensive Care Lund University and Lund University Hospital Lund Sweden Niels Juul, M.D. Department of Anaesthesia Aarhus University Hospital Aarhus C Denmark Carsten Kock-Jensen, M.D. Aarhus University Hospital Aarhus C Denmark Bertil Romner, M.D., Ph.D. Copenhagen University Hospital Copenhagen Denmark Knut Wester, M.D., Ph.D. Department of Surgical Sciences University of Bergen Bergen Norway Haukeland University Hospital Bergen Norway ISBN ISBN (ebook) DOI / Springer Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Berlin Heidelberg 2012 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (
6 Foreword I The Scandinavian Neurotrauma Committee (SNC) with its President Carsten Kock-Jensen has done a real service for those who care for severe traumatic brain injury (TBI) patients. These comprehensive TBI management recommendations allow the practitioner easy access to triage decisions and all possible diagnostics and therapeutics from injury site through rehabilitation with supporting evidence. While it is based on local expertise, it is heavily supported by current literature a combination that hopefully makes implementation that much easier. The fi rst step to improving TBI outcomes is to assess the literature. The next, more dif fi cult step is implementation. Changing TBI practice is a mandate since it is proven to dramatically reduce morbidity and mortality. Application of the Brain Trauma Foundation Guidelines ( org ) has been proven to improve patient outcomes and signi fi cantly reduce costs due to better patient outcomes (Faul et al., Journal of Trauma, 2007): 1. Patients are twice as likely to survive if BTF guidelines are followed. 2. Proportion of patients with good outcomes rose from 35% to 66%. 3. Proportion of patients with poor outcomes fell from 34% to 19%. 4. Potential savings $3.8 billion (US national). Similarly, a 50% reduction in deaths, even adjusted for confounding factors such as age, GCS, pupils, hypotension, and CT characteristics, has been achieved in New York State over the last 10 years (BTF article in submission) with an active TBI quality assurance program supported by an Internet database (TBI-Trac) and a free guidelines assessment tool at The reduction in deaths was accompanied by an increase in intracranial pressure monitoring in those patients that were recommended to have monitoring as described in the BTF Guidelines. Taking these Scandinavian TBI Guidelines and developing courses and tracking tools for compliance will ensure that the authors hard work will not be in vain, and more importantly, many TBI patient lives will be saved and the quality of life improved. Jamshid Gahjar, President, The Brain Trauma Foundation v
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8 Foreword II It is with great pleasure and with tremendous respect for the dedication and hard work performed by the Scandinavian Neurotrauma Committee (SNC), that I have witnessed the creation of the Scandinavian Practical guide to the management of severe traumatic brain injury. The SNC, which was initiated by the Scandinavian Neurosurgical Society, has since its foundation been dedicated to updating the Scandinavian neurosurgeons, neurointensivists, and neuroanaesthesiologists on the optimal treatment of patients with traumatic brain injury (TBI). This is the third major publication by the SNC. The fi rst publication in 2000 covered guidelines for the management of minimal, mild, and moderate head injuries, and this was followed in 2008 by guidelines for the prehospital management of severe TBI. Even though we consider Scandinavia as being one of the safest places on planet Earth, head injuries are still a major cause of morbidity and mortality, health-care costs, and catastrophic emotional turmoil for the victims and their families. This book covers the subject of TBI from A to Z in a very systematic and evidence-based fashion, formulated in such a way that it presents smooth and easy reading. The recurring paragraphs of Tips, tricks, and pitfalls are an ingenious way of highlighting the essentials. This book is relevant, both for the trainees in all specialties involved in the management and treatment of patients with TBI, but also a well-written update for the seasoned physician trauma treatment has improved. However, we should not only focus on what we can do for the head injured patients, i.e., preventing secondary brain injury, we should also get far more involved in preventing the primary brain injury. This means getting more involved in the political agenda and promoting trauma prevention initiatives. I am very proud of the work performed by the SNC, and I am sure that you will enjoy reading this book as much as I did. It should be found in any and all units dealing with trauma patients. Jannick Brennum, President, The Scandinavian Neurosurgical Society vii
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10 Acknowledgements The SNC would especially like to acknowledge the following institutions, all the contributing authors and the sponsors of committee meetings. Without you, this book project would not have been possible. Thank you! Institutions The Brain Trauma Foundation New York, USA Aarhus University Hospital Aarhus, Denmark Department of Anaesthesia and Intensive care Aarhus University Hospital Aarhus, Denmark Copenhagen University Hospital (Rigshospitalet) Copenhagen, Denmark Clinic for Neurosurgery University Hospital of Oulu Oulu, Finland Reykjavik University Hospital Reykjavik, Iceland University Hospital of North Norway Tromsø, Norway Haukeland University Hospital Bergen, Norway Karolinska University Hospital Stockholm, Sweden Department of Anaesthesia and Intensive Care University Hospital of Lund Lund, Sweden ix
11 x Acknowledgements Department of Anaesthesia and Intensive Care Halmstad Regional Hospital Halmstad, Sweden Umeå University Hospital Umeå, Sweden Authors Bellander, Bo-Michael Bloomfeld, Eric Brennum, Jannick Dahl, Bent Lob de Hoog, Bram Enblad, Per Engström, Martin Eskesen, Vagn Feldt-Rasmussen, Ulla Fink-Jensen, Vibeke Gahjar, Jamshid Grände, Per-Olof Guttormsen, Anne Berit Hermansson, Ann Hernæs, Jennie Hillered, Lars Howells, Tim Ingebrigtsen, Tor Johnsen, Birger Juul, Niels Frennström, Jan Kauppinen, Mikko Klose, Marianne Kock-Jensen, Carsten Koefoed-Nielsen, Jacob Kølsen-Petersen, Jens-Aage Koskinen, Lars-Owe D. Kvåle, Reidar Langhorn, Leanne Enggaard Marklund, Niklas Møller, Jens Kjølseth Naredi, Silvana Nielsen, Rasmus Philip Nielsen, Troels Halfeld Nordström, Carl-Henrik Olivecrona, Magnus Rasmussen, Mads Reinstrup, Peter Riis, Jens Jakob Romner, Bertil
12 Acknowledgements xi Ronne-Engström, Elisabeth Rønning, Pål André Rosenlund, Christina Skandsen, Toril Skrede, Steinar Sollid, Snorre Sørensen, Leif Hovgaard Springborg, Jacob Bertram Steiness, Morten Zebitz Sundstrøm, Terje Tietze, Anna Ulvik, Atle Undén, Johan Vik, Anne Wang, Mikala Welling, Karen Lise Wester, Knut Wulf-Eskildsen, Helle Åstrand, Ramona Sponsors Meda Denmark Codman Johnson & Johnson Roche Diagnostics Storz
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14 Contents Part I Epidemiology 1 Epidemiology Snorre Sollid and Tor Ingebrigtsen Part II Classi fi cation and Assessment 2 Classi fi cation of Head Injury Ramona Åstrand and Bertil Romner 3 Primary Clinical Assessment Jacob Bertram Springborg and Vagn Eskesen Part III Prehospital Management 4 Prehospital Management of Severe Traumatic Brain Injury (TBI) Snorre Sollid 5 What the Neurosurgeon Wants to Know: What, Who, When, and Where? Knut Wester 6 Transportation: Choice of Anaesthetic Drugs Niels Juul Part IV Admission, Diagnostics and Planning 7 Trauma Team Alert Christina Rosenlund 8 The Trauma Team Christina Rosenlund 9 Trauma Protocol (ABCDE) Christina Rosenlund xiii
15 xiv Contents 10 Multi-trauma Triage Christina Rosenlund 11 Cervical Spine Injury Christina Rosenlund 12 Radiological Evaluation of Head Traumas Helle Wulf Eskildsen, Anna Tietze, and Vibeke Fink-Jensen 13 Radiological Evaluation of Cervical Spine Traumas Helle Wulf Eskildsen, Anna Tietze, and Vibeke Fink-Jensen 14 Blood Samples Rasmus Philip Nielsen 15 Prognosis of Severe Traumatic Brain Injury: To Treat or Not to Treat, That Is the Question Magnus Olivecrona 16 Potential Organ Donor: Organ Preservation Silvana Naredi Part V Acute Surgical Treatment 17 Basic Trauma Craniotomy Terje Sundstrøm and Knut Wester 18 Surgical Management of Traumatic Intracranial Haematomas Terje Sundstrøm and Knut Wester 19 Surgical Management of Penetrating Brain Injuries Terje Sundstrøm and Knut Wester 20 Decompressive Craniectomy Pål André Rønning 21 Skull Fractures Pål André Rønning 22 Vessel Injuries Pål André Rønning 23 Insertion of Intracranial Monitoring Devices Mikko Kauppinen 24 Maxillofacial Fractures Ann Hermansson
Management of Severe Traumatic Brain Injury
Management of Severe Traumatic Brain Injury Evidence, Tricks, and Pitfalls Bearbeitet von Terje Sundstrom, Per-Olof Grände, Carsten Kock-Jensen, Niels Juul, Bertil Romner, Knut Wester 1. Auflage 2012.
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