Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY AND RESUSCITATION 117
observation in unit capable of close nursing observation
and frequent neurological reassessment for at least the
first 12 to 24 hours. A follow-up CT scan within 24 hours
is recommended if the initial CT scan is abnormal or
the patient’s neurological status deteriorates.
Management of Severe Brain Injury
(GCS Score 3–8)
Approximately 10% of patients with brain injury who
are treated in the ED have a severe injury. Such patients
are unable to follow simple commands, even after
cardiopulmonary stabilization. Although severe TBI
includes a wide spectrum of brain injury, it identifies
the patients who are at greatest risk of suffering
significant morbidity and mortality. A “wait and see”
approach in such patients can be disastrous, and prompt
diagnosis and treatment are extremely important.
Do not delay patient transfer in order to obtain a
CT scan.
The initial management of severe brain injury is
outlined in (n FIGURE 6-11). (Also see Initial Management
of Severe Brain Injury algorithm on MyATLS
mobile app.
n FIGURE 6-10 Algorithm for Management of Moderate Brain
Injury. (Adapted with permission from Valadka AB, Narayan RK,
Emergency room management of the head-injured patient. In:
Narayan RK, Wilberger JE, Povlishock JT, eds., Neurotrauma. New
York, NY: McGraw-Hill, 1996.)
of Moderate Brain Injury algorithm on MyATLS
mobile app.)
On admission to the ED, obtain a brief history and
ensure cardiopulmonary stability before neurological
assessment. Obtain a CT scan of the head and contact a
neurosurgeon or a trauma center if transfer is necessary.
All patients with moderate TBI require admission for
Pitfall
PREVENTION
Primary Survey and
Resuscitation
Brain injury often is adversely affected by secondary
insults. The mortality rate for patients with severe brain
injury who have hypotension on admission is more than
double that of patients who do not have hypotension.
The presence of hypoxia in addition to hypotension
is associated with an increase in the relative risk of
mortality of 75%. It is imperative to rapidly achieve
cardiopulmonary stabilization in patients with severe
brain injury. n BOX 6-2 outlines the priorities of the
initial evaluation and triage of patients with severe
brain injuries. (Also see Appendix G: Disability Skills.)
A patient with a
GCS score of 12
deteriorates to a
GCS score of 9.
• Reevaluate the patient
frequently to detect any
decline in mental status.
• Use narcotics and sedatives
cautiously.
• When necessary, use
blood gas monitoring or
capnography to ensure
adequate ventilation.
• Intubate the patient when
ventilation is inadequate.
Airway and Breathing
Transient respiratory arrest and hypoxia are common
with severe brain injury and can cause secondary brain
injury. Perform early endotracheal intubation in
comatose patients.
Ventilate the patient with 100% oxygen until blood
gas measurements are obtained, and then make
appropriate adjustments to the fraction of inspired
oxygen (FIO2). Pulse oximetry is a useful adjunct,
and oxygen saturations of > 98% are desirable. Set
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