Management of Neurotrauma Emergencies

Initial Assessment and Prioritization

• The World Journal of Emergency Surgery recommends that all exsanguinating patients with life-threatening hemorrhage require immediate intervention for bleeding control before addressing brain injuries 1, 2
• Urgent neurological evaluation must be performed, including assessment of pupils, Glasgow Coma Scale motor score, and brain CT scan to determine brain injury severity, as suggested by the World Journal of Emergency Surgery 2, 3
• The World Journal of Emergency Surgery advises that all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 3, 4

Airway and Ventilation Management

• The Anaesthesia journal recommends secure airway control through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring, even during pre-hospital care 5
• The World Journal of Emergency Surgery suggests maintaining arterial partial pressure of oxygen (PaO2) between 60-100 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• The World Journal of Emergency Surgery and the Anaesthesia journal recommend maintaining arterial partial pressure of carbon dioxide (PaCO2) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 1, 5

Hemodynamic Management

• The World Journal of Emergency Surgery recommends maintaining systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1, 6
• The Anaesthesia journal suggests a higher target of systolic blood pressure >110 mmHg for adults prior to measuring cerebral perfusion pressure 5, 7
• The World Journal of Emergency Surgery advises maintaining a cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring becomes available, adjusting based on neuromonitoring data and cerebral autoregulation status 4

Blood Product Management

• The World Journal of Emergency Surgery recommends transfusing red blood cells for hemoglobin level <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• The World Journal of Emergency Surgery suggests maintaining a platelet count >50,000/mm³ for life-threatening systemic hemorrhage, with higher values advisable for emergency neurosurgery including ICP probe insertion 1
• The World Journal of Emergency Surgery advises maintaining prothrombin time (PT)/activated partial thromboplastin time (aPTT) <1.5 normal control during interventions for life-threatening hemorrhage or emergency neurosurgery 1

Intracranial Pressure Management

• The World Journal of Emergency Surgery recommends ICP monitoring for patients at risk for intracranial hypertension, regardless of the need for emergency extra-cranial surgery 2, 4
• The Anaesthesia journal suggests considering external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 5

Imaging

• The Anaesthesia journal recommends performing brain and cervical CT scan without delay in severe traumatic brain injury patients 5, 7
• The Anaesthesia journal suggests considering early exploration of supra-aortic and intracranial arteries using CT-angiography in patients with risk factors 5

Special Considerations

• The World Journal of Emergency Surgery advises developing protocols for simultaneous multisystem surgery in patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery 4
• The Praxis Medical Insights journal recommends restricting physical and cognitive activities during the first days after TBI to minimize symptom exacerbation 8