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Traumatic Brain Injury: A Roadmap for Accelerating Progress (2022)

Chapter: 5 Acute Care After Traumatic Brain Injury

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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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5

Acute Care After Traumatic Brain Injury

Acute injury management immediately following traumatic brain injury (TBI) focuses on minimizing complications, identifying sequelae, and optimizing long-term outcomes. This chapter provides an overview of care during the initial assessment of TBI, as well as acute-stage care after the injury. The chapter summarizes current practices and identifies clinical needs and knowledge gaps.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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OVERVIEW OF CARE PROVIDED DURING THE ACUTE PHASE AFTER TBI

Because there are so many types of TBI, varying widely in severity and occurring in many different settings, patients with TBI may encounter the health care system in very different ways (see Figure 5-1). Many factors affect a person’s pathway of care from entry to exit, as well as the health care providers engaged along the way. Immediately after a TBI, patients may be treated by first responders and prehospital care practitioners, such as emergency medical services (EMS) personnel and paramedics. During the acute care process, patients are often transferred in and out of settings that include the injury site, emergency medical transport vehicles, emergency departments (EDs), hospital intensive care units (ICUs), operating rooms (ORs), and hospital wards. In other cases, a person with a TBI may be evaluated outside of EMS and trauma care settings, may be seen in an urgent care clinic or a primary care office, or may receive no immediate medical care after the injury. This second pathway is more likely if the initial injury was less severe. In a population-based survey in Colorado, approximately 38 percent of people who reported experiencing a TBI were seen in an ED, 23 percent were hospitalized, 10 percent were seen in a physician’s office, and 28 percent

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FIGURE 5-1 People who experience a TBI may follow different pathways for evaluation and potential care. Path 1: Many people who experience a TBI do not interact with the trauma care system, particularly if their initial injury is considered mild. For example, on-site evaluation may indicate that they do not require transport to a hospital, or they may report an incident or symptoms to a primary care provider. Some people will nevertheless require follow-up and further services in the post-acute and longer-term period. Path 2: Other people with a TBI require acute medical care through civilian or military trauma care systems. This pathway is most likely if the injuries sustained are more severe. After discharge from an acute care hospital stay, a further series of pathways are possible for care and community reintegration (see Chapter 6).
* After acute care hospitalization, a person may receive care from multiple types of facilities and in multiple care combinations (e.g., inpatient rehabilitation, to transitional care, to home; or discharge, to skilled nursing facility, to long-term care). The path taken by any given person depends on factors including injury severity and anticipated outcomes.
** Follow-up and support services available to people with TBI and their families once they are home or in a community setting also vary widely (e.g., from interdisciplinary and TBI-specialized outpatient rehabilitation, to supported employment services, to nothing).
Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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did not seek care (Whiteneck et al., 2016). While some patients die as a result of their injury, many will move past the acute phase of care (see Chapter 6).

The pathway followed by an individual after TBI is determined by the injury mechanism and severity, as well as local resources. Injury severity and presenting symptoms guide decisions on whether to transport patients to EDs and trauma centers, as well as on the medical interventions provided. Acute care management emphasizes the prevention and mitigation of secondary injuries that increase morbidity and mortality, such as hypotension, hypoxia, and increased intracranial pressure that may occur because of the primary insult to the brain (Vella et al., 2017). If the injury requires surgery, acute management will typically involve attempts to reduce intracranial pressure prior to the operation. The medical condition of patients also may deteriorate during the acute care phase, requiring clinical reassessment and escalation of the care provided. Knowing how to provide the best care in this complex system of specialists and care settings requires accurate diagnostic assessment, triage, and information coordination among providers.

TBI CLASSIFICATION

Classification is fundamental to the study of the natural history of disease and can provide a taxonomy for diagnosis, prognosis, and treatment. For nearly 50 years, the Glasgow Coma Scale (GCS) has provided a practical method for assessing and classifying TBI patients for clinical care and research. Patients are assessed and assigned a numerical score for each of the three components of the scale—based on eye opening (E), verbal response (V), and motor response (M). Their GCS score then is communicated as three numbers (e.g., E4V4M6) (Teasdale and Jennett, 1974). See Figure 5-2 for an overview of the GCS scoring elements.

The summing of these separate subscale scores into a single sum, or total, score (e.g., GCS 14) was initially used for research, but was quickly adopted by clinicians as a convenient shorthand. This led to less precise individual patient information and created issues surrounding sum scores when a subscale component was untestable or missing (e.g., verbal response for an intubated patient). In time, these GCS sum scores were further reduced to the categories of mild TBI (GCS 13–15), moderate TBI (GCS 9–12), and severe TBI (GCS 3–8). While this was meant to simplify TBI classification, the widespread use of these broad categories has had unintended consequences for TBI clinical care and research. Similar to cancer and other complex diseases, TBI is a heterogeneous condition with many pathoanatomical subtypes that cannot be fully captured or characterized in a singular GCS composite score. Today, one could not imagine classifying cancer as “mild, moderate, and severe” for diagnosis, treatment, and prognosis. Changes to TBI classification approaches are already being implemented in some areas. In the setting of sport-related concussion, for example, guidelines have abandoned former “grading scales” in favor of multidimensional assessment to determine injury severity, track recovery, and inform a stepwise protocol for return to play.

When the full range of the GCS sum score (GCS 3–15) is used, in the absence of confounders, it is associated with a variety of other measures of TBI severity, recovery, and prognosis. Lower GCS values are associated with the occurrence of loss of consciousness (LOC) and longer duration of posttraumatic amnesia (PTA), a clinically important measure of injury severity (McMillan et al., 1996). Although the GCS was developed before computed tomography (CT) and magnetic resonance imaging (MRI), a lower GCS value is associated with a higher likelihood of TBI-related CT and MRI abnormalities (Amyot et al., 2015). Associations also are found between lower GCS values and higher levels of blood-based biomarkers of glial (such as glial fibrillary acidic protein [GFAP]) and neuronal (such as ubiquitin carboxy-terminal hydrolase L1 [UCH-L1]) injury (Okonkwo et al., 2013; Papa et al., 2012), even among

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Image
FIGURE 5-2 Glasgow Coma Scale
NOTE: The minimum Glasgow Coma Scale score is 3, while the maximum score is 15, indicating that a person is awake and responsive.
SOURCE: Reprinted from Teasdale et al., 2014, with permission from Elsevier.

those at the mildest end of the TBI continuum (GCS 15) (McCrea et al., 2020). However, a number of confounders, such as intoxication, sedation, intubation, dementia, and language issues that can affect the validity of the GCS score obtained, limit use of the GCS as a standalone measure for TBI classification (Zuercher et al., 2009). These confounders contribute to what is thought to be excessive use of CT imaging for the diagnosis of TBI, despite the fact that the CT result is often normal and is not as sensitive as MRI (Yue et al., 2019; Yuh et al., 2013).

Not only is the current classification of acute TBI as mild, moderate, or severe crude, but it also promotes bias that can limit care. Patients with “mild TBI” often receive no follow-up care based on the assumption that spontaneous full recovery will occur, despite the growing realization that a subset of these patients experience persistent symptoms and impairments after mild TBI (Nelson et al., 2019). Conversely, a nihilistic approach is taken to many individuals with “severe” injury, including early withdrawal of life-sustaining therapy, despite evidence that some of these patients can achieve significant improvement in global functional outcome (McCrea et al., 2021) (see the section on disorders of consciousness below). While mild, moderate, and severe as categories for TBI are diagnostically blunt, they also fail to characterize the pathoanatomical type and extent of injury. Such coarse categorization of TBI undercuts prognostic utility with respect to predicting the course of recovery and outcome for individual TBI patients. These categories may also have contributed to multiple failed clinical trials in TBI (Samadani, 2016). In a recent article, Haarbauer-Krupa and colleagues (2021, p. 3242) conclude that “work is needed to use the diverse existing data available to develop a taxonomy of TBI that incorporates injury mechanisms and early biomarkers to develop standard phenotypes and improve symptom trajectories.”

Results from large-scale studies over the last decade support the use of imaging and blood-based biomarkers, along with the GCS, in the evolution of a more precise and informative classification system for TBI. This evolution is analogous to that of cancer classification. Cancer was initially characterized based on primary site or organ, tumor size, lymph node involvement, and presence of metastases. With increasing cohort sizes and extensive research,

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

protein expression was included (e.g., epidermal growth factor receptor), and now genetic and epigenetic features are commonplace in the classification of cancer for targeted treatment.

CT imaging remains the workhorse of TBI assessment in the ED because it provides objective evidence of acute injury and identifies pathoanatomical features that require different types of clinical management. In fact, findings of CT imaging are the most important factor in hospital triage and surgical decision making in TBI (Bullock et al., 2006; Ratcliff et al., 2014). CT imaging features are also well-known prognostic biomarkers in patients with more significant injury (GCS 3–12), and more recently, the prognostic importance of CT imaging features has been extended to patients historically described as having sustained mild TBI (GCS 13–15) (Yuh et al., 2021). The diagnostic and prognostic utility of CT imaging helps explain why it is overused, even though the risks of radiation exposure are known (Kirsch et al., 2011). Although CT imaging is fast and readily available, the use of MRI is slowly increasing because it is more sensitive and safer. MRI can identify TBI-related pathology when the CT scan is normal, and emerging evidence supports its prognostic utility (Yue et al., 2019), although MRI is not as widely available as CT, may require intrahospital transport, and takes longer to perform. When available, however, both of these imaging modalities provide information that can contribute to a more precise TBI classification system.

There is also increasing evidence for the inclusion of blood-based biomarkers in an improved TBI classification system. Recent studies demonstrate that blood biomarkers can reliably predict the presence of intracranial bleeding on head CT, which could potentially reduce the volume of unnecessary CT studies in acute care settings. As discussed further below, these and other data helped support recent Food and Drug Administration (FDA) approval of GFAP and UCH-L1 as biomarkers for use in ruling out the need for head CT (Wang et al., 2021). Furthermore, blood biomarkers are associated with the type and extent of specific TBI pathologies (e.g., contusion, diffuse axonal injury) in neurotrauma patients, which is a critically important step toward achieving a precision medicine model for TBI (Okonkwo et al., 2020; Yue et al., 2019). Blood biomarkers also have prognostic utility, including an association between GFAP/UCH-L1 levels acutely (<24 hours postinjury) and functional outcome out to 12 months post-TBI (Okonkwo et al., 2013). Broader evidence suggests that blood biomarkers have diagnostic and prognostic utility across the full spectrum of TBI severity, from concussion to coma. Blood-based biomarkers provide prognostic information that is above and beyond information from a clinical exam (Frankel et al., 2019). In addition to data on patients with more severe TBI treated at Level 1 trauma centers, recent studies demonstrate significantly elevated levels of GFAP and UCH-L1 in athletes with sport-related concussion and in military service members with mild TBI (all GCS 15) that are also predictive of time to return to activity after injury (Giza et al., 2021; McCrea et al., 2020; Pattinson et al., 2020).

Although GCS values, neuroimaging, and blood-based biomarkers are strongly correlated, they each provide unique and complementary information, and an ideal classification system is therefore one that leverages all three measures of brain injury severity. Blood-based biomarkers of glial and neuronal injury quantify the extent of brain cell injury irrespective of the injury’s location or functional consequences. Neuroimaging also provides information on the extent of brain cell and vascular injury, but it also provides information on the location and anatomic consequences of the injury (e.g., midline shift). The GCS score provides information on the functional consequences of the injury. Therefore, the incorporation of all three measures into a composite classification system would allow a multifaceted characterization of the injury, thereby reducing this heterogeneous condition to more homogeneous subsets that could become more focused targets for therapeutic intervention. Incorporating additional information from such sources as blood-based biomarkers could also aid decision making around when to use CT and/or MRI scans.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

Collectively, extensive research over the past two decades supports the concept that the full range of GCS values, imaging findings, and blood biomarker results can be incorporated into a more accurate and sophisticated TBI classification model to aid in more precise pathoanatomical characterization, inform individualized treatment, and aid in predicting long-term outcome after TBI.

TOOLS FOR ACUTE EVALUATION OF TBI

Additional diagnostic tools are needed for acute-stage evaluation and risk stratification of TBI. Beyond the GCS and the brain CT scan, there are no standardized tools for assessing TBI in the ED. In the context of mild TBI or concussion, symptom assessments, such as the Rivermead Postconcussion Questionnaire (RPQ), are often used to evaluate patients in non-ED outpatient settings. For patients who are military service members or athletes, acute evaluation of TBI also includes the use of standardized assessment tools. These tools include short batteries of neurocognitive tests, neuropsychiatric tests, and symptom inventories, such as the Standardized Assessment of Concussion (SAC), the Sports Concussion Assessment Tool (SCAT5) (Echemendia et al., 2017; McCrea, 2001), and the Military Acute Concussion Evaluation 2 (MACE 2).1 However, there are no standardized tools for assessing civilian TBI in the ED. The SAC, SCAT5, and MACE 2, among others, have not been validated for use in the ED because, relative to military and athlete patient populations, an ED typically sees more severely injured patients with a higher prevalence of comorbid conditions and patients who are injured by more varied injury mechanisms. As a consequence, TBI is often underdiagnosed in the ED (Blostein and Jones, 2003; Powell et al., 2008). Patients who have a negative head CT result are often told they are fine, and in more than 50 percent of cases, a diagnosis of TBI is not indicated on the patient’s chart (Powell et al., 2008). While many of those who experience a mild TBI do indeed recover, some experience ongoing symptoms, and tools are needed to help emergency medicine providers identify which patients are unlikely to recover quickly on their own.

THE ROLE OF CLINICAL PRACTICE GUIDELINES IN INFORMING ACUTE TBI CARE

Clinicians draw on evidence-based clinical practice guidelines (CPGs), where available, to inform their choices about patient care and interventions across the range of TBI severity. According to the Institute of Medicine, “clinical practice guidelines are statements and recommendations intended to optimize patient care and are informed by systematic reviews of evidence and assessment of the benefits and harms of alternative care options” (IOM, 2011, p. 15). For example, the “Guidelines for Guidelines” from the Department of Veterans Affairs (VA) outlines how key questions are formulated, what types of evidence will be considered, how the strength of the evidence will be graded, how disclosures of conflict of interest will be handled, how literature reviews will be conducted, and how Veteran/patient input will be reviewed, among other parameters (VA, 2019). The results of guideline development processes by such entities as the VA, medical associations, professional societies, expert panels, the Brain Trauma Foundation, and other nonprofit organizations inform standards of care for patient populations with TBI (see Box 5-1).

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1 See https://health.mil/Reference-Center/Publications/2020/07/30/Military-Acute-Concussion-Evaluation-MACE-2 (accessed September 24, 2021).

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

PREHOSPITAL EVALUATION AND TREATMENT OF TBI

The initial evaluation and treatment of TBI often begin at the scene of injury, which may be a war zone, roadside, sideline of a sporting event, or dark alley. Given that half of the deaths from TBI occur within 2 hours of injury, acute care in that crucial early window is a critical determinant of survival (Boto et al., 2006). Prehospital providers are often responsible for the rapid evaluation, initial resuscitation, and timely transport of suspected TBI patients. They must also contend with the resource constraints of a prehospital clinical examination, which may include lack of access to needed medical supplies; the need to attend to multiple trauma across organ systems; lack of time to perform a procedure; and the need to account for any special circumstances that may call for a different course of clinical care for individual patients, such as age, intoxication, allergic sensitivity, known medical history, and preexisting conditions. Note that in focusing on the care pathways of those TBI patients who receive acute emergency and hospital-based care, this chapter references other important types of TBI, but it does not delve in detail into out-of-hospital care provided by athletic trainers or other sports medicine practitioners, as is common in the management of sport-related concussion.

Assessing TBI

As noted earlier, EMS personnel are often the first health care providers to evaluate and stabilize TBI patients before they are transported to the hospital. Assessment of TBI in the prehospital setting involves monitoring vital signs, especially blood pressure and blood oxygen saturation; calculating the GCS score or pediatric GCS score; and examining the pupils for dilation and reactivity. These parameters may be assessed repeatedly to monitor clinical

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

improvement or deterioration. Although other TBI classifications exist, management and transportation decisions are often based on the patient’s GCS score in the prehospital setting.

The GCS score has limitations as a metric for assessing TBI in the prehospital setting, however. The score is based on the patient’s subjective responses to questions (or those of a witness speaking on the patient’s behalf), which may not be an accurate reflection of their status, and on a clinical examination for signs and symptoms that may be subtly present. TBI patients who initially present with a GCS score in the normal range may nonetheless harbor traumatic intracranial pathologies. However, prehospital providers lack tools with which to identify “hidden TBI” patients who would benefit from being transported to a trauma center for further evaluation and care. Novel point-of-care diagnostic tools beyond the GCS and clinical examination are needed to optimize prehospital care.

Prehospital Triage and Medical Transport

Prehospital evaluation and decisions about medical transport are informed by guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Brain Trauma Foundation (Badjatia et al., 2008; Sasser et al., 2012). In general, the prehospital guidelines recommend transporting patients with GCS ≤12, those with penetrating head trauma, those experiencing high-risk falls or motor vehicle collisions, and those taking anticoagulant medications “to a facility that provides the highest level of care within the defined trauma system” (Sasser et al., 2012, p. 8). For example, because patients with low GCS scores have a high likelihood of harboring traumatic intracranial lesions and elevated intracranial pressure, guidelines generally recommend transporting these patients to facilities that offer immediate access to CT scans and neurosurgical care.

Individual jurisdictions determine how protocols for prehospital care are implemented within their jurisdiction. According to a recent report from the National Academies of Sciences, Engineering, and Medicine,

Nationwide, there are an estimated 21,283 credentialed EMS agencies, comprising a mixture of private, public, and volunteer systems that often operate independently and sometimes at odds with each other. There is no one-size-fits-all configuration for EMS.… EMS providers generally follow medical protocols that may be local (applying only to a single agency), countywide, regional, or statewide. (NASEM, 2016, p. 82)

Significant differences in prehospital protocols across regions of the United States make both care coordination between the prehospital and hospital settings and triage of patients more challenging. This variability has particular effects on care management situations in which “optimal care of injured patients is delayed or limited by geography, weather, distance, or resources” (ACS, 2014, p. 94) or providers’ lack of experience. Yet, standardizing emergency care is difficult because of the history of emergency care development and reliance on local physicians and local systems.2

In combat zones, as well as in remote or austere locations, medical evacuation from the injury scene may be delayed for hours or even days. Even when rapid evacuation is possible, transport time may be prolonged. For example, the transport of injured active duty service

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2 Robinson, J. 2021. TBI Care Gaps and Opportunities: Provider Perspectives on the Acute-Stage Continuum of Care. Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 18, 2021.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

members by Critical Care Air Transport Teams3 can take anywhere from 30 minutes to 16 hours or longer (Ingalls et al., 2014). Care en route is often challenged by loud ambient noise, heat, pressure, lack of appropriate equipment, and turbulence. Accordingly, emergency and frontline responders may need to manage patients who are sicker than they are accustomed to, for longer than they are equipped to handle, with fewer resources than what they have on hand, and in a challenging location. These conditions have given rise to the emerging concept of prolonged field care, which involves providing field medical care beyond the timelines conventionally called for in order to decrease patient mortality and morbidity (Shackelford et al., 2021).4

Prehospital Acute Care Management

While prehospital care is guided by the concept that care provided during the first 60 minutes following traumatic injury (“the Golden Hour”) is critical in determining whether a patient survives the injury, it has become increasingly clear that secondary insults occurring beyond the Golden Hour increase the risk for mortality and disability (Stocchetti et al., 2017). Accordingly, constructs that guide care during the acute period are avoiding secondary injury, as well as aiding areas of the brain with reduced blood perfusion (the ischemic penumbra) to ensure maximum recovery.

The goals of acute TBI care management in the prehospital setting are to avoid the “3 Hs”: hypoxia, hypotension, and hyper- or hypoventilation. Hypoxia (low blood oxygen level) can be corrected by providing supplemental oxygen, which may include intubating those patients with airway compromise (Vandromme et al., 2011). Hypotension (low blood pressure) is corrected by controlling hemorrhaging and administering fluids. Hypoventilation may be managed with mechanical ventilation. Hyperventilation can be avoided by controlling the number of breaths delivered during bag valve mask or mechanical ventilation. Prehospital care guidelines that highlight the importance of avoiding and treating the 3 Hs have been shown to improve the odds of a patient’s surviving at least until admission to the hospital and decreasing overall mortality in persons with severe TBI (Spaite et al., 2019).

However, these interventions can come with risks, and there are also uncertainties in what is known about optimal prehospital care. For example, some studies indicate that when intubation is performed in a prehospital setting, unwanted side effects of hyperoxygenation and hypo- or hypercarbia increase the odds of poor patient outcomes (Davis et al., 2006). The literature on civilian urban trauma also has shown that patients have superior or similar outcomes if they are transported directly to a trauma center by means other than EMS (Demetriades et al., 1996; Winter et al., 2021). It is unclear why this is the case, but potential explanations include earlier arrival to definitive care or avoidance of interventions that have been associated with worse outcomes during transport (Schreiber et al., 2015). In another example, a recent study of 438 military patients evacuated out of theater during 2007 to 2014 found that patients with moderate to severe TBI were more likely to survive and return to duty if evacuated more than 3 days after injury, suggesting that a stabilization period may be beneficial prior to evacuation (Maddry et al., 2020). Further work would be needed to

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3 Critical Care Air Transport Teams (CCATTs) consist of an ICU-level physician, an ICU nurse, and a respiratory therapist. Transport is most frequently performed in two legs: from the origin country to Landstuhl, Germany, where the patient has an initial stay, and then from Germany to the continental United States. Transferring patients by CCATT is most similar to transporting ICU patients to the CT scanner and back in a hospital, except the transfer can take up to 16 hours.

4 Further information about the concept of Prolonged Field Care is also available from the Special Operations Medical Association at http://www.specialoperationsmedicine.org/pages/pfcresources.aspx (accessed August 26, 2021).

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

understand this finding. Overall, there is a paucity of prehospital research on TBI, which makes it difficult to understand what works well for these patients in prehospital settings.5 More research is needed to develop and implement guidelines and support best practices in prehospital settings so as to reduce adverse outcomes of TBI (Gravesteijn et al., 2020).

Telemedicine offers one opportunity to improve care prior to arrival at a definitive trauma center for advanced TBI care (Raso et al., 2021; Shah et al., 2020; Whiting et al., 2021). It enables expert clinicians to have both audio and visual access to the prehospital scene and provide real-time on-scene direction to EMS personnel. Such extension of the reach of expert clinicians may allow patients in low-resource areas, especially those in rural settings, to access care comparable to that provided at regional trauma centers. It may also prevent unnecessary transfers to trauma centers (Latifi et al., 2018). Further investigation of the feasibility of prehospital telemedicine consults in TBI and the effect of such consultation on clinical outcomes is warranted.

Handoff from Prehospital to Hospital-Based Care

If prehospital services indicate that a patient’s injuries require further intervention, the patient may be transferred to a hospital or trauma center. Often, this handoff entails challenges of inadequate coordination, leading to discontinuities in patient care (Robertson et al., 2014). For example, there are currently no standardized processes for ensuring that key information is exchanged between dispatch and EMS personnel and between EMS and ED personnel (Reay et al., 2020; Stiell et al., 2003).

Another gap is the lack of integration of prehospital data with subsequent hospital and outpatient data. Data from care delivered in the prehospital setting are often not transmitted to the hospital in a structured, easy-to-use format (Martin et al., 2018; Wood et al., 2015). The lack of data integration and lack of a formal process for communication of key information from prehospital to ED providers limit the ability to deliver optimal care to TBI patients. The lack of data integration and the episodic nature of prehospital and hospital care also confound research on prehospital TBI care, and research in prehospital settings has been recognized as a critical challenge in both the United States and Europe (Maurin Söderholm et al., 2019). The Excellence in Prehospital Injury Care (EPIC) study—a large-scale public health effort to conduct prehospital research over multiple systems, patients, and years—may serve as a model for the conduct of prehospital research in TBI.6 This study, in which more than 130 Arizona state and local EMS agencies participated, assessed the use and effectiveness of prehospital TBI guidelines for those with moderate to severe TBI (Spaite et al., 2019). Participants received training in the guidelines, and the study found that adherence to the guidelines increased survival to hospital admission.

HOSPITAL-BASED EVALUATION AND CARE

Emergency Department

Each year approximately 4.8 million ED visits occur in which people are evaluated for a potential TBI, and it is estimated that TBI is diagnosed in 2.5 million of these visits (Korley et al., 2016). In the ED, TBI severity is typically determined by clinical examination, including GCS, and by head CT imaging where available and indicated.

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5 Robinson, J. 2021. TBI Care Gaps and Opportunities: Provider Perspectives on the Acute-Stage Continuum of Care. Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 18, 2021.

6 Ibid.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

In the ED setting, evaluation for TBI focuses primarily on identifying life-threatening injuries. As a result, limited time and attention are devoted to identifying injuries that present with subtle signs and symptoms. People who are assessed as having a normal GCS score and do not appear significantly impaired may nonetheless have “hidden TBI” that may be revealed only with further imaging or testing, while patients with more substantial trauma may be resuscitated with limited attention to an underlying TBI. The American College of Surgeons’ Advanced Trauma Life Support program offers limited guidance for resuscitation of TBI patients, focused in particular on controlling traumatic hemorrhage.7 In patients with GCS <15 an evaluation is frequently multidisciplinary and may involve clinicians from the ED, trauma surgery, neurosurgery, and anesthesiology. Care includes managing the airway, blood oxygenation, intracranial pressure, and hemorrhaging. Standardized guidelines are especially needed on how to prevent hemodynamic deterioration in TBI patients during acute care.

In the ED, a brain CT scan is performed in 82 percent of TBI evaluations (Korley et al., 2016). Approximately 90 percent of suspected TBI patients who receive a head CT scan are classified as negative for TBI, with 9 percent showing traumatic intracranial lesions (Korley et al., 2016). Clinical decision rules exist for determining which patients to recommend for brain CT imaging (Haydel et al., 2000; Jagoda et al., 2008; Kuppermann et al., 2009; Shetty et al., 2016; Stiell et al., 2001); however, adherence to these decision rules is variable (DeAngelis et al., 2017).

As discussed above, FDA recently approved two blood-based biomarkers of TBI—GFAP and UCH-L1—that may be useful in guiding assessment in the ED, including the appropriate use of head CT scans. By January 2021, FDA had given the green light for clinicians to use a platform that measures these biomarkers at the point of care (see Phillips, 2021). Measurement of the blood-based biomarker troponin has revolutionized the emergent assessment of chest pain by providing a rapid test to facilitate diagnosis and triage (Gibbs and McCord, 2020). The expanding use of FDA-approved blood-based biomarkers for TBI similarly has the potential to transform TBI assessment.

The majority of research on TBI biomarkers to date has focused on diagnostic markers of acute TBI, including markers of blood–brain barrier integrity; neuroinflammation; and axonal, neuronal, astroglial, and vascular injury. (See Appendix B for additional information on biomarker research.) Clinical availability of blood-based biomarkers for TBI is expected to expand in 2022 and beyond, and studies are needed to determine the effectiveness of these tools in guiding TBI care and decreasing inappropriate use of head CT during TBI evaluation. Future studies will also be needed to explore biomarker profiles over time that may help in monitoring for longer-term sequelae of TBI.

As noted previously, emerging data suggest that MRI scans may also be useful in the acute risk stratification of TBI, being both safer and more sensitive than CT: approximately a third of TBI patients with negative head CT results have MRI findings of traumatic intracranial injuries that are associated with poorer outcomes (Yuh et al., 2013). Given that brain MRI often requires transport to a remote location in the hospital for a prolonged period, however—posing a potential safety risk, especially for the most severely injured patients—decision aids are needed to identify which TBI patients are likely to benefit from acute MRI brain imaging.

Care in the ICU and Hospital Ward

For moderate and severe TBI, hospital-based care may involve patient transfer from the ED to an ICU or medical ward. In the hospital, TBI management consists of the assessment and stabilization of vital signs, the assessment of severity based on the GCS; a neurologic

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7 See https://www.facs.org/quality-programs/trauma/atls (accessed September 24, 2021).

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

exam; and imaging of the brain, most commonly with a CT scan. In the ICU, additional monitoring of physiologic parameters may occur in hopes of preventing secondary brain injury. The monitoring may include intracranial pressure (ICP), cerebral perfusion pressure (CPP), partial brain tissue oxygenation (PbtO2), brain metabolism, and brain activity.

Nearly all professional societies that publish guidelines on the treatment of TBI in the ICU use a similar stepwise algorithm. For example, current therapies sequentially involve elevating the head of the bed; using sedation and hyperosmolar fluids; avoiding fever; draining off cerebrospinal fluid to treat elevated ICP; and in cases of refractory elevated ICP and cerebral herniation, employing mild transient hyperventilation.

Traumatic intracranial lesions identified on CT scan include epidural, subdural, subarachnoid, and intraparenchymal hemorrhages; patients may have one type or a combination of these lesions, and different lesions have different prognoses (Yuh et al., 2021). For example, isolated epidural hemorrhages have an excellent prognosis if they are diagnosed early and treated with surgical evacuation, whereas subdural and subarachnoid hemorrhages are associated with disability and higher mortality. A person’s prognosis is influenced by lesion size and location; time to diagnosis; and patient factors, including age, comorbid medical conditions, and use of anticoagulant/antiplatelet therapy. Approximately 25–60 percent of patients with traumatic intracranial lesions experience progression in lesion size, which may be detected by deterioration in clinical neurologic examination or on repeat brain CT scan (Allard et al., 2009; Narayan et al., 2008; Servadei et al., 2000). The incidence of lesion progression is influenced by the severity of the injuries in the patient population that is studied, and the risk for progression is greatest during the 24 hours following injury. A major barrier to delivering optimal management for these patients is the lack of objective tools for detecting lesion progression prior to the development of overt clinical signs or radiographic indication. Recently, a number of authors have questioned the utility of 6-hour repeat brain CT scans in GCS 13–15 TBI patients with traumatic intracranial lesions (Joseph et al., 2014; Rosen et al., 2018). Studies are needed to better define the subpopulation of TBI patients with traumatic intracranial lesions that are at risk for lesion progression and therefore warrant close monitoring.

Operating Room and Anesthesia Care

Patients with TBI requiring urgent surgical decompression spend varying amounts of time in the ED. Some patients receive rapid visual assessments followed by transport to the OR. Intraoperative CT scan prevents the need for transport to radiology suites for postoperative head CT scan and minimizes transport risks. Blood biomarkers are not currently used to evaluate treatment response during intraoperative TBI care.

The intraoperative goal for TBI care is to prevent secondary brain injury by optimizing such key physiologic parameters as CPP and brain tissue oxygenation. Doing so involves optimizing systemic blood pressure and ICP and peripheral oxygenation status by providing a balanced anesthetic, continued resuscitation, continuous monitoring, and life-sustaining hemodynamic management. To these ends, intraoperative TBI care requires timely readiness of an OR, availability of needed equipment, and nursing support. Patients with TBI who present for emergent craniotomy often have polytrauma, requiring that craniotomy be performed simultaneously with control of other injuries, which in turn necessitates coordination among surgical, nursing, and anesthesiology teams.

Patients with TBI and extracranial injuries requiring surgical intervention during the acute period may have ICP monitors in place, which allows for determination and maintenance of CPP. Brain oxygen monitoring systems (such as Licox monitors) provide additional information for brain tissue monitoring.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

For patients with mild or moderate TBI, optimizing brain physiology is important to prevent postoperative worsening of ICP and TBI. For patients with traditionally defined mild or moderate TBI, attention to contusion size and intraoperative ICP may drive the decision to extubate patients at the end of surgery.

Intrahospital Handoffs and Transport

Patients hospitalized with TBI can undergo a number of intrahospital transports. Handoffs from ED to OR or inpatient hospital staff present the risk of adverse events (Horwitz et al., 2009), as do handoffs from OR to ICU. Handoffs are accompanied by information on demographics, intraoperative blood loss, surgical procedures performed, complications, and anticipated events upon transfer. Patients can suddenly deteriorate during transfer, and monitoring standards may vary, presenting challenges for patient transport within the hospital. Ideally, transporting staff should have the ability and equipment to stabilize patients who deteriorate during intrahospital travel. Transport is often facilitated by nursing staff, and most hospitals have nursing guidelines on intrahospital transport of critically ill patients (Fanara et al., 2010; Nathanson et al., 2020; Warren et al., 2004). Monitor alarms are set using age-specific parameters to account for pediatric or geriatric physiology, and patients are typically monitored with an electrocardiogram (ECG) monitor, blood pressure monitor, and pulse oximetry during transport. Similarly, during hospitalization in acute care and while transitioning to post-acute care, referral to specialists may not occur. Thresholds for consultation are not uniform and the process is often delayed, which results in suboptimal care and outcomes.

VARIATION IN CONTENT OF AND ADHERENCE TO CLINICAL CARE GUIDELINES

In addition to ensuring that the best available evidence is used to guide therapy, adherence to clinical care guidelines limits unwarranted variation in practice while not precluding personalized care. Absent more comprehensive clinical care guidelines, the provision of optimal care for acute TBI faces multiple challenges (Brolliar et al., 2016; Carney et al., 2017; Kochanek et al., 2019). Limited data on certain topics and variable adherence to existing guidelines both contribute to gaps in acute care for TBI.

Adherence to clinical care guidelines and protocols has been shown to improve outcomes following TBI. A 2007 study found that adherence to Brain Trauma Foundation guidelines resulted in better health outcomes for adult patients (Faul et al., 2007). In a study of children with severe brain injuries, adherence to pediatric guidelines was associated with survival at discharge and improved scores on the Glasgow Outcome Scale. Each percentage increase in guideline adherence was associated with a 6 percent lower risk of death (Vavilala et al., 2014). A study on adherence to return-to-play protocols for children experiencing sport-related TBI similarly found that “increased adherence to protocols predicted successful return to sport without symptom exacerbation” (DeMatteo et al., 2020, p. 7).

Guideline adherence is variable, however, with one review finding a range of 18–100 percent (Cnossen et al., 2021). This variability can be driven by a combination of guideline, provider, and institutional factors (Brolliar et al., 2016), including the strength of evidence supporting the guidelines, provider attitudes and experience, and the institution’s culture around the implementation of care guidelines. The existence of multiple guidelines directed at different medical specialties caring for different types of TBI populations and covering different topics or using different standards of evidence for what is included or excluded

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

from the guidelines also contributes to variability in the choices made by care providers and in the care patients receive. Payer influences and clinician bias contribute to variability in adherence to guidelines as well.

Limitations of Care Guidelines for TBI: Example of Intracranial Pressure (ICP) Monitoring

Clinical practice guidelines can also be of limited utility in some circumstances. ICP monitoring is the standard of care for severe TBI and is used frequently (Liu et al., 2015). However, monitoring of ICP has not been proven beneficial for improving patient outcomes (Marehbian et al., 2017; Shafi et al., 2008). Moreover, there is no standardization regarding indications and methods for ICP monitoring, and monitoring practices vary, including whether to use intraparenchymal or external ventricular drains to help regulate a patient’s ICP (Cnossen et al., 2017; Van Cleve et al., 2013). Accordingly, parenchymal pressure monitors and external ventricular drains are routinely used interchangeably in trauma centers.

A number of other approaches are used to manage ICP, many of which carry risks and have side effects. These approaches include catecholamine drugs, barbiturates, surgical decompression, abdominal decompression, brain tissue oxygenation, resuscitation, provision of adequate cerebral perfusion, osmolar therapy, decompressive craniectomies, and nutrition support (Aarabi et al., 2006; Cook et al., 2008; Joseph et al., 2004). More work is needed to identify which patients are most likely to benefit from any or all of these approaches. Given that other TBI tests and treatments are predicated on ICP monitoring, the lack of standardization in this aspect of care results in unwarranted variability in acute TBI management.

More robust clinical care guidelines are also needed to address important aspects of TBI care that lack a clear consensus, such as the use of tranexamic acid (Maas et al., 2021), the use of a high fraction of inspired oxygen, the optimal target partial pressure of carbon dioxide, optimal anesthesia care, the order of prioritization of surgical interventions for different organ systems in polytrauma, and optimal blood transfusion thresholds.

Limitations of Care Guidelines for TBI: Example of Cerebral Perfusion Pressure (CPP) Management

Weak adherence to TBI guidelines may be affected by the lack of compelling clinical data on whether interventions are beneficial, leading to greater variability in case-by-case management. As an example, the choice of vasopressors to augment CPP is based largely on clinician or institutional preference. Even when vasopressors are used, standard resuscitation targets for both ICP and CPP are lacking.

PREPARATION FOR TRANSFER TO POST-ACUTE CARE

Patients with TBI often need early rehabilitation after hospital admission or discharge to inpatient and outpatient rehabilitation. Integrating rehabilitation consultation early in acute care has been shown to improve patient outcomes (see Chapter 6), but the timing and structure of rehabilitation consultations vary, and rehabilitation interventions are variably introduced during the acute care period. Referrals to rehabilitation services and the availability of follow-up care after TBI are also highly variable and frequently absent, particularly

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

for vulnerable populations and patients without access to primary care. These issues are discussed further in Chapter 6.

Prior to discharge, patients with TBI need to be screened for discharge to a safe environment. By the time of discharge, acute care providers also need to have provided materials and resources on the person’s brain injury to the person with TBI and their family. Providing education and support to persons with TBI and caregivers starting in the acute care phase is especially important for those patients being discharged to home. And while the military has systems of care to provide post-acute services and long-term rehabilitation, patients can experience loss of continuity when transitioning from Department of Defense (DoD) to Department of Veterans Affairs (VA) health systems (Randall, 2012). Care coordinators or patient navigators can facilitate smoother transitions for patients and families, but they are not routinely used in civilian medicine (Livergant et al., 2021; Natale-Pereira et al., 2011).

SPECIAL CHALLENGES IN ACUTE TBI MANAGEMENT

Penetrating versus Blunt TBI

While both penetrating and blunt brain injury are classed as TBI, important differences are associated with these two injury types. Blunt brain injury is a diffuse disease in which the entire brain is typically affected. While injury to the bony skull may occur, the wounding mechanism is the concussive force that is applied to the brain. In penetrating brain injury, the wounding missile traverses the brain, causing injury in its path. Penetrating injuries can be caused by fragments from explosions, bullets, and other sources. Skull fracture is common, and additional injury may occur as shards of bone are driven into the brain, causing secondary injury. Outcomes from penetrating brain injury are worse than those from blunt injury, and the mortality rate is higher (Larkin et al., 2018; Orman et al., 2012; Skarupa et al., 2019). This may be due to the severity of the brain injury but also to other associated life-threatening injuries.

Treatment for penetrating brain injury has largely been supportive, and operative therapy has not been a mainstay of care. This may be changing, however. Observational research from the wars in Iraq and Afghanistan suggests that an aggressive management approach for penetrating brain injury, including through decompressive craniectomy, results in good outcomes compared with historical controls (Bell et al., 2010). Penetrating brain injury is also becoming a more important civilian issue. Rates of civilian penetrating brain injury have increased, with a recent review of trauma admissions indicating an increase from 3,042 per 100,000 population in 2010 to 7,578 per 100,000 in 2014 (Skarupa et al., 2019). This issue may become increasingly important given that suicide by firearm injury has become a leading cause of TBI-related mortality (Daugherty et al., 2019), and the occurrence of violence in the United States has been increasing. Further research will be needed to address prevention and clinical management specifically for penetrating TBI.

Multiple Trauma

Patients who have multiple types of trauma (multitrauma or polytrauma) and severe TBI are often critically ill and present a special challenge. For example, bleeding lowers blood pressure, which can worsen outcomes of TBI. Sites of blood loss must be quickly identified and bleeding controlled, with surgery if necessary. The anesthesia needed for surgical procedures may also decrease blood pressure, potentially worsening secondary brain injury.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

The inflammatory response to operative therapy, the so-called “second hit,” may affect TBI outcome as well (Hinson et al., 2015). Specific injuries are often treated with medications to lower blood pressure, at least temporarily; such is the case, for example, with thoracic aortic injury, to prevent aortic rupture. The result is competing interests as clinicians attempt to treat both conditions.

As another example, patients who have suffered multiple injuries often have long-bone fractures. Ideal therapy involves early operative fracture fixation, but the ideal timing of fracture fixation in patients with TBI remains uncertain (Scalea et al., 1999, 2000). For patients with TBI who also have polytrauma, then, clarity is needed regarding the optimal timing of surgery for noncranial surgical procedures. Patients who have blunt trauma with combined hemorrhage and TBI present a dilemma in that they may require operations for hemorrhage control but at the same time may have life-threatening intracranial processes that are not diagnosed because they need to bypass the CT scanner on the way to the OR. Rapid methods of diagnosing intracranial hemorrhage and determining the optimal time to repair long-bone fractures are needed.

Confounding Factors and Comorbidities

During hospitalization and during the transition from acute to post-acute care for TBI, many patients have comorbidities and preexisting conditions that require ancillary services in addition to TBI care. In addition to other types of traumatic injuries, such comorbidities and preexisting conditions commonly include cardiovascular risk factors, such as hypertension, and mental health disorders, among others. A review of TBI hospitalizations in Canada found a trend toward increasing age, along with a trend toward “increasing severity, comorbidity, and length of stay among TBI hospitalizations” (Fu et al., 2015, p. 452).

Clinicians may give inadequate attention to comorbidities and preexisting conditions or fail to consider strategies for minimizing side effects, such as pain, during TBI care. Although pain is one of the leading complaints among patients with TBI (Nampiaparampil, 2008), a systematic and holistic approach to pain management for these patients is seldom the norm. Clinicians do not have many options for adjunctive treatments to offer patients. Patients with TBI are also at increased risk of substance use disorders, and the American College of Surgeons’ (ACS’s) guidance requires ACS-verified trauma centers to undertake injury prevention efforts and to screen patients for alcohol abuse (ACS, 2014). However, substance abuse screening is not performed consistently.

Disorders of Consciousness and Withdrawal of Life-Sustaining Therapies

Making prognostic judgments in cases of severe TBI can be challenging, and it is therefore important to avoid making definitive predictions too early on while aiming to minimize unnecessary interventions.

Severe impairment in the short term did not portend poor outcomes in a substantial minority of patients with [moderate to severe] TBI. When discussing prognosis during the first 2 weeks after injury, clinicians should be particularly cautious about making early, definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment. (McCrea et al., 2021, p. E1)

It has been reported that 40 percent of patients thought to be unconscious actually are found to retain conscious awareness when they are reevaluated, and that five examinations

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

can bring the rate of misdiagnosis down to 5 percent, highlighting the importance of serial examination.8 An ethical framework has also been proposed for identifying covert consciousness, or consciousness that is not readily observed in hospitalized TBI patients (Edlow and Fins, 2018). However, many acute care providers are unaware of the available data on long-term functional progress after prolonged disorders of consciousness (DOC). It has been reported that life-sustaining treatment is withdrawn in 26 percent of severe TBI patients within 72 hours of injury, whereas many patients with severe TBI display signs of consciousness only 1–2 months after injury.9 Similarly, Edlow and Fins (2018, p. 2) note that in patients with DOC, “withdrawal of life-sustaining therapy accounts for up to 70% of TBI deaths in the intensive care unit (ICU), with decisions often made within 3 days of admission.” Diagnostic accuracy is improved through the use of evidence-based practice guidelines, which provide specific guidance on diagnostic assessment (Giacino et al., 2018); however, these guidelines still need to be widely translated into clinical practice.

Making prognostic and treatment judgments in cases of severe TBI also poses ethical challenges when a patient cannot engage in the decision-making process and exercise his or her agency, as is the case in patients with DOC. The sudden nature of traumatic injuries means that preplanning or advance care directives are often not in place, and family members may be uncomfortable with making health decisions for their loved ones.10 Decisions can be made that potentially result in withdrawing life-sustaining therapies too soon, especially when care teams are less familiar with the emerging evidence in patients with DOC.11

ADDITIONAL CONSIDERATIONS

Importance of Multidisciplinary Consultations

Optimal care for trauma patients involves consultation from many specialized services. Patients with severe TBI require transport to multiple sites, such as the OR or radiology suite. In acute care, trauma surgeons often must evaluate input from consultants in orthopedics, anesthesiology, maxillofacial surgery, interventional or trauma radiology, and neurocritical care to ensure that care is safe and coordinated, decide whether operative care is needed, and determine whether and how to place monitoring devices. In addition to physicians, care commonly also involves nurses, social workers, pharmacists, psychologists, physical therapists, occupational therapists, and speech therapists.

However, coordination of care among these specialists during acute care and between acute and post-acute care falls short of optimal. Given the many health science disciplines involved in acute care for patients with TBI, an interdisciplinary approach is required for optimal care and outcomes, with care being coordinated on a timeline of anticipated trajectories across disciplines. Such an approach entails, for example, obtaining a nutrition consult early after admission to optimize brain metabolism and recovery, and, again soon after admission, consulting the appropriate specialists to optimize resources, care, and outcomes. Yet, while recognized as a best practice, teamwork in the care of TBI patients is not always rewarded by health systems, which can contribute to less than optimal collaboration across disciplines.

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8 Giacino, J., R. Nakase-Richardson, and J. Whyte. 2021. Disorders of Consciousness After Traumatic Brain Injury: A Virtual Workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, May 24, 2021.

9 Ibid.

10 Allen Davis, J. 2021. System Challenges for TBI Care. Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 30, 2021.

11 Ibid.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

Communication in handoffs between practitioners is critical to ensure that information is exchanged clearly and accurately, as dropped information can be disastrous.

Pediatric and Geriatric TBI

Special considerations apply for evaluation and/or treatment of TBI in both pediatric and geriatric populations. A number of special considerations are important for acute TBI management in pediatric patients (Kochanek et al., 2019). Because the center of gravity in young people lies in their head, their falls produce a TBI more commonly relative to other age groups. In addition to falls, pediatric TBI can result from abusive head trauma (shaking) and from nonaccidental and accidental trauma. As a result, “clinicians must always consider abuse in differential diagnosis when evaluating and treating children, when the mechanism of injury is unclear or reported history does not match injuries or [the child’s] age” (Smith et al., 2019, p. 119). Special factors pertinent to children also include the need for age-dependent hemodynamic management and reference to the pediatric TBI guidelines for care.

Care for TBI in older adults entails additional considerations. It must be stressed, moreover, that while there are guidelines for acute care of adults with severe TBI, data on geriatric TBI care and outcomes remain insufficient (Gardner et al., 2018). For example, few or no guidelines address the management of dangerous blood clotting in older adult patients. Geriatric patients often have some degree of cerebral atrophy due to advanced age. Therefore, significant bleeding or clots can initially accumulate with minimal symptoms. These patients often develop severe symptoms quickly when the accumulated blood causes cerebral herniation. The use of anticoagulation, common in older patients, can exacerbate intracranial hemorrhage. A major care gap for geriatric TBI patients is a lack of consensus on the need for reversing the effects of modern anticoagulation drugs and antiplatelet agents to avoid progression of intracranial bleeding (Gardner et al., 2018). Other geriatric TBI considerations during surgery include attention to elderly physiology and frailty.

In both pediatric and geriatric populations, assessing brain injury and its progression can be extremely challenging when the patient is nonverbal, cognitively impaired, or cognitively delayed. TBI commonly clouds the sensorium, and patients may be unable to cooperate with standard neurological testing.

Other Considerations for Patient-Centered Care

Patients who are nonbinary or noncisgender are vulnerable to clinicians’ lack of experience in addressing their concerns.12 Transgender people may be at greater risk for violence compared with cisgender people, and individuals who are nonbinary or non-gender-conforming need to receive unbiased care. In addition, much remains unknown about the role of biological sex hormones in TBI outcomes, including potential effects of hormone therapies (Duncan and Garijo-Garde, 2021).

Since TBI may render patients with or without limited English proficiency unable to provide consent, preoperative discussions with family members may be needed. In a study of family-centered care after pediatric TBI, for example, families with limited English proficiency recalled a variety of acute care communication and coordination challenges (Moore et al., 2015). It is important for care providers to be sensitive to the varied circumstances and needs of their patients.

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12 Moore, M. 2021. Disparities in TBI Outcomes. Presentation and panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 16, 2021.

Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
×

CONCLUSIONS

It is critically important for clinicians to avoid missing a diagnosis of TBI during acute care evaluation for trauma-related injuries. A missed diagnosis is a missed opportunity to inform patients about recovery from TBI and to provide a referral to inpatient or outpatient rehabilitation or further follow-up. Missed diagnoses also contribute to underestimating the true burden of TBI at the population level. However, an improved classification system for TBI is needed. A TBI taxonomy reduced to “mild, moderate, and severe” is insufficient diagnostically, is of limited value prognostically, and fails to stratify patients adequately into TBI clinical trials.

Patient-centered care during the acute period after a TBI has been sustained needs to achieve an appropriate balance between reducing unwanted variation and enabling the provision of medicine personalized by age, sex, patient preferences, and other factors. However, many patients do not benefit from the best evidence-based care after experiencing a TBI. All patients with TBI should receive guideline-based care, where available. However, guideline, provider, and institutional factors all affect variations in TBI care. Care recommendations and decision tools exist for mild and severe TBI in pediatric and adult populations, but implementation of these guidelines is variable, and the existing guidelines vary significantly with respect to the topics covered, the level of detail, and the criteria for inclusion of studies in evidence syntheses.

A number of additional knowledge gaps and clinical care challenges continue to constrain prompt and accurate diagnosis and management of acute-stage TBI in prehospital and hospital settings. Needs include further incorporating biomarkers and multimodal information in diagnostic and outcome prediction tools to provide greater personalization and improvement in care after TBI; filling evidence gaps in such areas as prehospital stabilization, surgical timing, and optimal management in the context of comorbidities, potential medical interactions, and multiple trauma; and fostering effective information exchange and coordination across the multiple locations and phases of care and among the different specialties involved.

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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Suggested Citation:"5 Acute Care After Traumatic Brain Injury." National Academies of Sciences, Engineering, and Medicine. 2022. Traumatic Brain Injury: A Roadmap for Accelerating Progress. Washington, DC: The National Academies Press. doi: 10.17226/25394.
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Every community is affected by traumatic brain injury (TBI). Causes as diverse as falls, sports injuries, vehicle collisions, domestic violence, and military incidents can result in injuries across a spectrum of severity and age groups. Just as the many causes of TBI and the people who experience it are diverse, so too are the physiological, cognitive, and behavioral changes that can occur following injury. The overall TBI ecosystem is not limited to healthcare and research, but includes the related systems that administer and finance healthcare, accredit care facilities, and provide regulatory approval and oversight of products and therapies. TBI also intersects with the wide range of community organizations and institutions in which people return to learning, work, and play, including the education system, work environments, professional and amateur sports associations, the criminal justice system, and others.

Traumatic Brain Injury: A Roadmap for Accelerating Progress examines the current landscape of basic, translational, and clinical TBI research and identifies gaps and opportunities to accelerate research progress and improve care with a focus on the biological, psychological, sociological, and ecological impacts. This report calls not merely for improvement, but for a transformation of attitudes, understanding, investments, and care systems for TBI.

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