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Timing of Extracerebral Operations in Severe Traumatic Brain Injury Patients

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Controversies in Severe Traumatic Brain Injury Management

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Abstract

Care of the polytrauma patient with severe traumatic brain injury (TBI) requires the clinician to navigate among sometimes conflicting priorities, concerns, and objectives—toward a goal of optimizing outcomes and minimizing potential harms. For all polytrauma patients, the initial triage and resuscitation effort should be focused and efficient, with an emphasis on attending to the “ABCs.” For the patient with comorbid severe TBI, this phase of care must superimpose considerations relevant to the treatment of primary brain injury and mitigation of secondary insults.

Coordination of the timing of interventions for injuries extrinsic to the intracranial compartment requires effective communication among care providers and an ongoing assessment of relative risks and benefits for a given intervention for the individual patient. In the absence of hemodynamic instability, central nervous system pathology may take precedence. However, if the patient is hemodynamically unstable, aggressive resuscitation and perhaps, emergent, damage control intervention on the part of the trauma team may be indicated. Associated craniofacial injuries typically are not life-threatening and do not require emergent intervention for repair. CSF fistulae often develop in a delayed fashion and may necessitate multidisciplinary intervention for definitive repair if the patient fails more conservative measures. Orthopedic injuries commonly occur in concert with TBI. While early definitive care is optimal, there is a role for initial damage control and subsequent staged definitive intervention if the severity of the head injury precludes safe operation in the acute setting.

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References

  1. Leading causes of death age group 2014 [dataset on the Internet]. National Vital Statistics System, National Center for Health Statistics, CDC; 2016 [cited 2016 Dec 26]. Available from: https://www.cdc.gov/injury/wisqars/leadingcauses.html

  2. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths: Atlanta, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

    Google Scholar 

  3. Sauaia A, Moore FA, Moore EE, Haenel J, Read R, Lezotte D. Early predictors of postinjury multiple organ failure. Arch Surg. 1994;129:39–45.

    Article  CAS  Google Scholar 

  4. Border JR, LaDuca J, Seibel R. Priorities in the management of the patient with polytrauma. Prog Surg. 1975;14:84–120.

    Article  CAS  Google Scholar 

  5. Tscherne H, Oestern HJ, Sturm JA. Stress tolerance of patients with multiple injuries and its significance for operative care [in German]. Langenbecks Arch Chir. 1984;364:71–7.

    Article  CAS  Google Scholar 

  6. Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.

    Article  CAS  Google Scholar 

  7. Butcher N, Enninghorst N, Sisak K, Balogh ZJ. The definition of polytrauma: variable interrater versus intrarater agreement – a prospective international study among trauma surgeons. J Trauma. 2013;74:884–9.

    Article  Google Scholar 

  8. Lefering R, Paffrath T, Linker R, Bouillon B, Neugebauer EAM, German Society for Trauma. Head injury and outcome – what influence do concomitant injuries have? J Trauma. 2008;65:1036–44.

    Article  Google Scholar 

  9. Sumann G, Kampfl A, Wenzel V, Schobersberger W. Early intensive care unit intervention for trauma care: what alters the outcome? Curr Opin Crit Care. 2002;8:587–92.

    Article  Google Scholar 

  10. McMahon C, Yates D, Campbell F, Hollis S, Woodford M. Unexpected contribution of moderate traumatic brain injury to death after major trauma. J Trauma. 1999;47(5):891.

    Article  CAS  Google Scholar 

  11. Regel G, Lobenhoffer P, Grotz M, Pape H-C, Lehmann U, Tscherne H. Treatment results of patients with multiple trauma: an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center. J Trauma. 1995;38:70–8.

    Article  CAS  Google Scholar 

  12. Gross T, Schüepp M, Attenberger C, Pargger H, Amsler F. Outcomes in polytraumatized patients with and without brain injury. Acta Anaesthesiol Scand. 2012;56:1163–74.

    Article  CAS  Google Scholar 

  13. Zeckey C, Hildebrand F, Pape H-C, Mommsen P, Panzica M, Zelle BA, et al. Head injury in polytrauma – is there an effect on outcome more than 10 years after the injury? Brain Inj. 2011;25:551–9.

    Article  Google Scholar 

  14. Lecky FE, Bouamra O, Woodford M, Alexandrescu R, O’Brien SJ. Epidemiology of polytrauma. In: Pape H-C, Peitzman AB, Schwab CW, Giannoudis PV, editors. Damage control management in the polytrauma patient. Berlin: Springer Science + Business Media, LLC; 2010. p. 13–23. https://doi.org/10.1007/978-0-387-89508-6_2.

    Chapter  Google Scholar 

  15. The ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International ATLS Working Group. Advanced trauma life support (ATLSâ): the ninth edition. J Trauma Acute Care Surg. 2013;74:1363–6.

    Article  Google Scholar 

  16. Tisherman SA, Barie P, Bokhari F, Bonadies J, Daley B, Diebel L, et al. Resuscitation endpoints. J Trauma. 2004;57:898–912.

    Article  Google Scholar 

  17. Ransahoff RM. The chemokine system in neuroinflammation: an update. J Infect Dis. 2002;186(Suppl 2):S152–6.

    Article  Google Scholar 

  18. Stahel PF, Mc M-K, Kossmann T. The role of the complement system in traumatic brain injury. Brain Res Rev. 1998;27:243–56.

    Article  CAS  Google Scholar 

  19. Gebhard F, Huber-Lang M. Polytrauma – pathophysiology and management principles. Langenbeck's Arch Surg. 2008;393:825–31.

    Article  CAS  Google Scholar 

  20. Stahel PF, Smith WR, Moore EF. Role of biological modifiers regulating the immune response after trauma. Injury. 2007;38:1409–22.

    Article  Google Scholar 

  21. Piek J, Chesnut RM, Marshall LF, van Berkum-Clark M, Klauber MR, Blunt BA, et al. Extracranial complications of severe head injury. J Neurosurg. 1992;77:901–7.

    Article  CAS  Google Scholar 

  22. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216–22.

    Article  CAS  Google Scholar 

  23. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. J Trauma. 1996;40:764–7.

    Article  CAS  Google Scholar 

  24. Wald SL, Shackford SR, Fenwick J. The effect of secondary insults on mortality and long-term disability after severe head injury in a rural region without a trauma system. J Trauma. 1993;34:377–81.

    Article  CAS  Google Scholar 

  25. Chi JH, Knudson M, Vassar MJ, McCarthy MC, Shapiro MB, Mallet S, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma. 2006;61:1134–41.

    Article  Google Scholar 

  26. Jeremitsky E, Omert L, Dunham CM, Protetch J, Rodriguez A. Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma. 2003;54:312–9.

    Article  Google Scholar 

  27. Bouma GJ, Muizelaar JP. Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury. J Neurotrauma. 1992;9(Suppl 1):S333–48.

    PubMed  Google Scholar 

  28. Marion D, Darby J, Yonas H. Acute regional cerebral blood flow changes caused by severe head injuries. J Neurosurg. 1991;74:407–13.

    Article  CAS  Google Scholar 

  29. Rose J, Valtonen S, Jennett B. Avoidable factors contributing to death after head injury. Br Med J. 1977;2:615.

    Article  CAS  Google Scholar 

  30. Certo TF, Rogers FB, Pilcher DB. Review of care of fatally injured patients in a rural state: five year follow up. J Trauma. 1983;23:559–65.

    Article  CAS  Google Scholar 

  31. Foley RW, Harris LS, Pilcher DB. Abdominal injuries in automobile injuries. J Trauma. 1977;23:611–5.

    Article  Google Scholar 

  32. Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6–15.

    PubMed  Google Scholar 

  33. Wisner DH, Victor NS, Holcroft JW. Priorities in the management of multiple trauma: intracranial versus intra-abdominal injury. J Trauma. 1993;35:271–8.

    Article  CAS  Google Scholar 

  34. Huang M-S, Shih H-C, Wu J-K, Ko T-J, Fan V-K, Pan R-G, et al. Urgent laparotomy versus emergency craniotomy for multiple trauma with head injury patients. J Trauma. 1995;38:154–7.

    Article  CAS  Google Scholar 

  35. Moore JM, Thomas PAW, Gruen RL, Rosenfled CP. Simultaneous multisystem surgery: an important capability for the civilian trauma hospital. Clin Neurol Neurosurg. 2016;148:13–6.

    Article  Google Scholar 

  36. Hernandez AM, Roguski M, Qiu RS, Shepard MJ, Riesenburger RI. Surgeons’ perspectives on optimal patient positioning during simultaneous cranial procedures and exploratory laparotomy. South Med J. 2013;106:679–83.

    Article  Google Scholar 

  37. Gwyn PP, Carraway JH, Horton CE, Adamson JE, Mladick RA. Facial fractures: associated injuries and complications. Plast Reconstr Surg. 1971;47:225–30.

    Article  CAS  Google Scholar 

  38. Lim LH, Lam LK, Moore MH, Trott JA, David DJ. Associated injuries in facial fractures: review of 839 patients. Br J Plast Surg. 1993;46(8):635.

    Article  CAS  Google Scholar 

  39. Gautam V, Leonard EM. Bony injuries in association with minor head injury: lessons for improving the diagnosis of facial fractures. Injury. 1994;25:47–9.

    Article  CAS  Google Scholar 

  40. Luce EA, Tubb TD, Moore AM. Review of 1000 major facial fractures and associated injuries. Plast Reconstr Surg. 1979;63:26–30.

    Article  CAS  Google Scholar 

  41. Sinclair D, Schwartz M, Gruss JS, McLellan B. A retrospective review of the relationship between facial fractures, head injuries, and cervical spine injuries. J Emerg Med. 1988;6:109–12.

    Article  CAS  Google Scholar 

  42. Mulligan RP, Friedman JA, Mahabir RC. A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures. J Trauma. 2010;68:587–92.

    Article  Google Scholar 

  43. Mulligan RP, Mahabir RC. The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg. 2010;126:1647–51.

    Article  CAS  Google Scholar 

  44. Lee KF, Wagner LK, Lee YE, Suh JH, Lee SR. The impact-absorbing effects of facial fractures in closed head injuries: an analysis of 210 patients. J Neurosurg. 1987;66:542–7.

    Article  CAS  Google Scholar 

  45. Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope. 2003;113:102–6.

    Article  Google Scholar 

  46. Hohlrieder M, Hinterhoelzl J, Ulmer H, Lang C, Hackl W, Kampfl A, et al. Traumatic intracranial hemorrhages in facial fracture patients: review of 2,195 patients. Intensive Care Med. 2003;29:1095–100.

    Article  Google Scholar 

  47. Manson PN, Crawley WA, Yaremchuk MJ, Rochman GM, Hoopes JE, French JH. Midface fractures: advantages of immediate extended open reduction and bone grafting. Plast Reconstr Surg. 1985;76:1–12.

    Article  CAS  Google Scholar 

  48. Gruss JS, Mackinnon SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg. 1986;78:9–22.

    Article  CAS  Google Scholar 

  49. Thaller SR, Beal SL. Maxillofacial trauma; a potentially fatal injury. Ann Plast Surg. 1991;27(3):281.

    Article  CAS  Google Scholar 

  50. Ardekian L, Samet N, Shoshani Y, Taicher S. Life-threatening bleeding following maxillofacial trauma. J Craniomaxillofac Surg. 1993;21(8):336.

    Article  CAS  Google Scholar 

  51. Murakami WT, Davidson TM, Marshall LF. Fatal epistaxis in craniofacial trauma. J Trauma. 1983;23:57–61.

    Article  CAS  Google Scholar 

  52. Busuito MJ, Smith DJ, Robinson MC. Mandibular fractures in an urban trauma center. J Trauma. 1986;26(9):826.

    Article  CAS  Google Scholar 

  53. Tung T-C, Tseng W-S, Chen C-T, Lai J-P, Chen Y-R. Acute life-threatening injuries in facial fracture patients: a review of 1,025 patients. J Trauma. 2000;49:420–4.

    Article  CAS  Google Scholar 

  54. Derdyn C, Persing JA, Broaddus WC, Delashaw JB, Jane J, Levine PA, et al. Craniofacial trauma: and assessment of risk related to timing of surgery. Plast Reconstr Surg. 1990;86:238–45.

    Article  CAS  Google Scholar 

  55. Shibuya TY, Karam AM, Doerr T, Stachler RJ, Zormeier M, Mathog RH, et al. Facial fracture repair in the traumatic brain injury patient. J Oral Maxillofac Surg. 2007;65(9):1693.

    Article  Google Scholar 

  56. Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Korfali E, et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev. 2006;29:64–71.

    Article  Google Scholar 

  57. Brodie H, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol. 1997;18:188–97.

    CAS  PubMed  Google Scholar 

  58. Lewin W. Cerebrospinal fluid rhinorrhea in nonmissile head injuries. Clin Neurosurg. 1966;12:237–52.

    Article  Google Scholar 

  59. Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg. 2004;62:676–84.

    Article  Google Scholar 

  60. Mincy JE. Posttraumatic cerebrospinal fluid fistula of the frontal fossa. J Trauma. 1966;6:618–22.

    Article  CAS  Google Scholar 

  61. Friedman JA, Ebersold MJ, Quast LM. Persistent posttraumatic cerebrospinal fluid leakage. Neurosurg Focus. 2000;9:e1–5.

    CAS  PubMed  Google Scholar 

  62. Brodie H. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae. A meta-analysis. Arch Otolaryngol Head Neck Surg. 1997;123:749–52.

    Article  CAS  Google Scholar 

  63. Villalobos T, Arango C, Kubilis P, Rathore M. Antibiotic prophylaxis after basilar skull fractures: a meta-analysis. Clin Infect Dis. 1998;27:364–9.

    Article  CAS  Google Scholar 

  64. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015;(4):CD004884.

    Google Scholar 

  65. Archer JB, Sun H, Bonney PA, Zhao YD, Hiebert JC, Sanclement JA, et al. Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps. J Neurosurg. 2016;124:647–56.

    Article  Google Scholar 

  66. Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus. 2012;32:e3.

    Article  Google Scholar 

  67. Rocchi G, Caroli I, Belli E, Salvati M, Cimatti M, Delfini R. Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair. Surg Neurol. 2005;63:559–64.

    Article  Google Scholar 

  68. Banerjee M, Bouillon B, Shafizadeh S, Paffrath T, Lefering R, Wafaisade A, German Trauma Registry Group. Epidemiology of extremity injuries in multiple trauma patients. Injury. 2013;44:1015–21.

    Article  Google Scholar 

  69. Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg. 2003;85-B:478–83.

    Article  Google Scholar 

  70. Pape H-C, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002;183:622–9.

    Article  Google Scholar 

  71. Riska E, Von Bonsdorf H, Hakkinen S. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury. 1976;8:110–6.

    Article  CAS  Google Scholar 

  72. Riska E, Nyllynen P. Fat embolism in patients with multiple injuries. J Trauma. 1982;22:891–4.

    Article  CAS  Google Scholar 

  73. Seibel R, LaDuca J, Hassett JM, Babikian G, Mills B, Border DO, et al. Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure, septic state. Ann Surg. 1985;202:283–95.

    Article  CAS  Google Scholar 

  74. Bone LB, Johnson KD, Weigelt J, Schienberg R. Early versus delayed stabilization of femoral fractures. J Bone Joint Surg. 1989;71:336–40.

    Article  CAS  Google Scholar 

  75. Poole GV, Miller JD, Agnew SG, Griswold JA. Lower extremity fracture fixation in head-injured patients. J Trauma. 1992;32:654–9.

    Article  CAS  Google Scholar 

  76. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma. 1997;42:1–5.

    Article  CAS  Google Scholar 

  77. Fakhry SM, Rutledge R, Dahners LE, Kessler D. Incidence, management, and outcome of femoral shaft fracture: a statewide population-based analysis of 2805 adult patients in a rural state. J Trauma. 1994;37:255–60.

    Article  CAS  Google Scholar 

  78. Scalea T, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, et al. Early fracture fixation may be “just fine” after head injury: no difference in central nervous system outcomes. J Trauma. 1999;46:839–46.

    Article  CAS  Google Scholar 

  79. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollack AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48:613–23.

    Article  CAS  Google Scholar 

  80. Reynolds MA, Richardson JD, Spain DA, et al. Is the timing of fracture fixation important for the patient with multiple trauma? Ann Surg. 1995;222:470–81.

    Article  CAS  Google Scholar 

  81. Brundage S, McGhan R, Jurkovich GJ, Mack C, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002;52:299–307.

    PubMed  Google Scholar 

  82. Pape H-C, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53:452–62.

    Article  Google Scholar 

  83. Grotz MRW, Giannoudis PV, Pape H-C, Allami MK, Dinopoulos H, Kretteck C. Traumatic brain injury and stabilization of long bone fractures: an update. Injury. 2004;35:1077–86.

    Article  CAS  Google Scholar 

  84. Flierl MA, Stoneback JW, Beauchanp KM, Hak DJ, Morgan SJ, Smith WR, et al. Femur shaft fracture fixation in head-injured patients: when is the right time? J Orthop Trauma. 2010;24:107–14.

    Article  Google Scholar 

  85. Dunham CM, Bosse MJ, Clancy TV, Cole FJ, Coles MJM, Knuth T, et al. Practice management guidelines for the optimal timing of long-bone fracture stabilization in trauma patients: the EAST practice management guidelines work group. J Trauma. 2001;50:958–67.

    Article  CAS  Google Scholar 

  86. Gandhi RR, Overton T, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients–update. J Trauma. 2014;77:787–95.

    Article  Google Scholar 

  87. Pape H-C, Pfeifer R. Safe definitive orthopedic surgery (SDS); repeated assessment for tapered application of early definitive care and damage control? Injury. 2015;46:1–3.

    Article  CAS  Google Scholar 

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  1. Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA

    P. B. Raksin MD

  2. Division of Neurosurgery, John H. Stroger Jr. Hospital of Cook County (formerly Cook County Hospital), Chicago, IL, USA

    P. B. Raksin MD

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  1. Department of Neurosurgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA

    Shelly D. Timmons

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Raksin, P.B. (2018). Timing of Extracerebral Operations in Severe Traumatic Brain Injury Patients. In: Timmons, S. (eds) Controversies in Severe Traumatic Brain Injury Management. Springer, Cham. https://doi.org/10.1007/978-3-319-89477-5_13

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