What are the principles in assessing this patient?

What are the key features of his neurological examination? What is the Glasgow coma score (GCS) and why is this important?

What are the appropriate next investigations?

What do the tests show and what is the significance of the finding?

How should he be managed in the first few days?

What is the significance of the clinical signs and what should be done?

The patient is intubated emergently and an urgent CT head scan is performed. What does Figure 42.2 show?

Figure 42.2

His family ask what his prognosis is. What do you tell them?

A.1 The patient has sustained a traumatic brain injury and should be assessed using the standardized guidelines for all trauma patients. These include assessment of airway, breathing and circulation (A, B, C), immobilization of the cervical spine and the performance of a brief neurological examination (primary survey). Following this a more detailed secondary survey may be performed to look for further injuries. These principles are detailed in the emergency management of severe trauma (EMST) course manual available through the Royal Australasian College of Surgeons (Committee on Trauma, American College of Surgeons 2008).

A.2 The Glasgow coma score (GCS), originally reported by Drs Teasdale and Jennett in 1974 (Teasdale and Jennet 1974), is an attempt to quantify the level of consciousness of a patient with a head injury in a form which is standardized and hence comparable from place to place, from time to time, and from person to person. The three summed components include the response to eye opening (E), motor response (M) and verbal response (V) (Table 42.1).

Table 42.1 Glasgow coma scale

This patient is eye opening to voice (E3), localizes to painful stimulus (M5) and is orientated to place (V5) with a GCS of 13. The main utility of the GCS is to allow serial standardized neurological assessment of the head injured patient.

A.3 CT head and neck. Most trauma imaging protocols now have cranial and spinal imaging performed at the same time which allows exclusion of a significant bony spinal injury in the trauma patient.

A.4 The CT head scan shows a right occipital fracture with some intracranial air and a contrecoup left and right frontal haemorrhagic contusion. There is some mass effect with shift of the left frontal lobe toward the right (subfalcine herniation). There is also some blood on the tentorium cerebelli. These findings suggest that the patient has fallen, first striking the right occipital area and then through translation of the force contused the frontal lobes. This scan is concerning because of the size of the original contusion and already present mass effect and the propensity for these lesions to expand with time as a result of further haemorrhage and secondary oedema. Delayed neurological deterioration and even death can occur with such lesions.

A.5 Clinical management of traumatic brain injury is primarily concerned with the prevention of secondary injury including ischaemia, hypoxia, cerebral oedema, raised intracranial pressure, hydrocephalus, infection and seizure. Serial neurological observation (GCS) by trained nursing and medical staff and investigations including HR and BP, oxygen saturations, serum electrolytes and serial CT head scans provide the data on which to make evidence-based clinical judgement. All patients should have supplemental oxygen, careful fluid balance control to ensure euvolaemia and avoidance of hyponatraemia as well as seizure treatment or prophylaxis if clinically warranted, as in this patient.

A.6 Fixed dilated pupils and extensor posturing are late stages of brainstem herniation, implying disturbance at the level of the midbrain. The most common cause is raised intracranial pressure secondary to a mass lesion causing compression of the upper brainstem. As stated before, emergency care proceeds in a stepwise fashion of airway, breathing and circulation correction before diagnostic investigations. In this patient emergency intubation and ventilation is necessary. The patient may have had a seizure alone or progression of the intracranial mass lesion secondary to oedema, hyponatraemia or further haemorrhage resulting in cerebral herniation. If life-threatening raised intracranial pressure is suspected, as here, temporary hyperventilation to reduce CO₂ and intravenous mannitol 1 g/kg should be given on the way to CT.

A.7 The CT shows increased oedema around the left frontal, right frontal and left temporal contusions and more mass effect (subfalcine herniation) and also compression of the brainstem and hydrocephalus.

A.8 The patient has had a severe traumatic brain injury with resultant marked frontal lobe dysfunction. This is likely to remain a problem for the rest of his life and he will require extensive rehabilitation input. He is unlikely to return to his previous independent functional level because of impaired judgement and lack of insight. This is a tragic outcome, with enormous cost to patient, family and community.

Traumatic brain injury (TBI) is a significant public health problem. It is the number one cause of death in people under 40 and affects mainly young males and the elderly. In addition 2% of the population live with the sequelae of TBI in the community contributing to a major societal burden. Unfortunately, in spite of an enormous amount of research and development of evidence-based guidelines for the treatment of TBI, there are limited proven therapies for stopping the progression of the initial injury and the mortality from severe TBI has remained unchanged for the last two decades.

The cornerstone of clinical TBI management is the prevention of secondary injury. A thorough neurological assessment of the patient’s initial injury, including spinal injury, will establish a baseline. Evidence-based guidelines for both the medical and surgical management of traumatic brain injury are published and used in clinical practice. As highlighted in this case, even with close supervision on a neurosurgical unit a patient can deteriorate suddenly (talk and die) and may require life-saving surgery. Anticipation, prevention or timely treatment of secondary injury is therefore essential.