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Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

WSES · 2023 · international

Source and licence

Authors
Edoardo Picetti, Fausto Catena, Fikri Abu-Zidan et al.
Title
Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)
Journal
World Journal of Emergency Surgery : WJES, 2023
DOI
10.1186/s13017-022-00468-2
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC9830860

Licence statement of the original publication

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Results

  • We recommend that all salvageable (i.e., patients who may recover, at least to some extent, with appropriate treatment) severe isolated TBI patients needing or at risk of needing neurosurgery [i.e., for surgical mass lesion and/or ICP monitoring] admitted to a spoke center should be rapidly transferred to a hub center after hemodynamic and respiratory stabilizationLevel: Strong recommendation
  • We recommend the utilization of a telemedicine service for rapid digital image transfer from the spoke to the hub centerLevel: Strong recommendation
  • We recommend, before and during transfer from the spoke to the hub center, a continuous and clear collaboration/communication (i.e., check for availability of ICU bed/OR, significant clinical deterioration during transfer, etc.) between different medical specialties (anesthesiology/intensive care/neurocritical care, neurosurgery, neuroradiology, trauma surgery, etc.)Level: Strong recommendation
  • We recommend sedation, intubation and mechanical ventilation for the transfer of all severe TBI patientsLevel: Strong recommendation
  • We recommend that the transfer of severe TBI patients should be performed by appropriately trained and certified critical care transport personnel with experience in advanced airway management/life support strategies and basic knowledge of neurocritical care (i.e., medical management of cerebral swelling, herniation)Level: Weak recommendation
  • We recommend that severe salvageable TBI patients with signs/elevated risk of herniation and need for neurosurgery (brain CT scan already done in spoke hospital with neurosurgical consultation) should be directly transported form the spoke center to the OR at the hub centerLevel: Strong recommendation
  • We recommend, in severe TBI patients needing transfer to the hub center, an invasive monitoring of ABP in addition to the standard cardiorespiratory monitoring (ECG, HR, SpO2 and ETCO2)Level: Weak recommendation
  • We recommend maintaining SAP > 110 mmHg or mean arterial pressure MAP > 80 mmHg* in severe isolated TBI patients *In the case of invasive ABP monitoring, the arterial transducer should be zeroed at the level of the tragusLevel: Strong recommendation
  • We recommend maintaining PLT count > 75.000/mm3 in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)Level: Strong recommendation
  • We recommend maintaining PT/aPTT value < 1.5 the normal control in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)Level: Strong recommendation
  • We recommend early reversal of anticoagulant/antiplatelets agents, in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)Level: Strong recommendation
  • We recommend utilization of POC tests (i.e., TEG and ROTEM), if available, to optimize coagulation function in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)Level: Weak recommendation
  • We are unable to recommend the routine use of specific anti-seizure drugs in salvageable severe TBI patients presenting with seizure observed clinically and/or with EEGLevel: No recommendation
  • We recommend performing serial neurologic evaluations (GCS + pupil examination) in the spoke center and during transfer to the hub center to detect neurologic deterioration in patients without signs of intracranial hypertensionLevel: Strong recommendation
  • We recommend against discontinuation of sedation to obtain a reliable neurological evaluation in patients with radiological signs of intracranial hypertension (i.e., midline shift, compression of the basal cisterns, sulcal effacement, etc.). In this scenario, only pupil examination, especially during the transfer, would be usefulLevel: Strong recommendation
  • We are unable to recommend use of brain ultrasonography (i.e., optic nerve sheath diameter, cerebral blood flow waveform analysis, etc.), in the presence of skilled operators, as a reliable screening non-invasive tool for detection of intracranial hypertension in the spoke centerLevel: No recommendation
  • We are unable to recommend use of automated pupillometry, if available, as a reliable screening non-invasive tool for detection of intracranial hypertension in the spoke centerLevel: No recommendation
  • We recommend that performance of brain ultrasonography and/or automated pupillometry, if utilized in the spoke center, should not significantly delay the patient’s transferLevel: Strong recommendation
  • We recommend that severe isolated TBI patients should be maintained with a head of the bed elevated at 30°–45° to facilitate brain venous drainage in the spoke center and during transfer to the hub centerLevel: Strong recommendation
  • We recommend that in severe TBI patients, the head should be maintained in the midline avoiding compression of the neck veins in the spoke center and during transfer to the hub centerLevel: Strong recommendation
  • We recommend avoiding core body temperature > 37.5 °C and to aim for normothermia in severe TBI patientsLevel: Strong recommendation
  • We recommend maintaining Hb level > 7 g/dl in severe TBI patientsLevel: Strong recommendation
  • We recommend maintaining SpO2 > 94% in severe TBI patientsLevel: Strong recommendation
  • We recommend maintaining a PaCO2 of 35–38 mmHg in severe TBI patientsLevel: Strong recommendation
  • We recommend maintaining a serum Na level of 140–145 mEq/l in severe TBI patientsLevel: Strong recommendation
  • We recommend osmotherapy as a therapeutic maneuver to be utilized in patients with signs of intracranial hypertension/brain herniation awaiting emergent neurosurgeryLevel: Strong recommendation
  • We recommend short-term hyperventilation as a therapeutic maneuver that should be utilized only in patients with signs of brain herniation awaiting emergent neurosurgeryLevel: Strong recommendation
  • We recommend an increase in sedation, while maintaining an acceptable ABP, as a therapeutic maneuver that should be utilized in the management of patients with signs of brain herniation awaiting emergent neurosurgeryLevel: Strong recommendation
  • Recommendation 1We recommend that all salvageable (i.e., patients who may recover, at least to some extent, with appropriate treatment) severe isolated TBI patients needing or at risk of needing neurosurgery [i.e., for surgical mass lesion and/or intracranial pressure (ICP) monitoring] admitted to a spoke center should be rapidly transferred to a hub center after hemodynamic and respiratory stabilizationagreement %: 97.6, strong recommendation
  • Recommendation 7We recommend, in severe TBI patients needing transfer to the hub center, an invasive monitoring of arterial blood pressure (ABP) in addition to the standard cardiorespiratory monitoring [electrocardiogram (ECG), heart rate (HR), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2)]agreement %: 82.9, weak recommendation
  • Recommendation 8We recommend maintaining systolic arterial pressure (SAP) > 110 mmHg or mean arterial pressure (MAP) > 80 mmHg* in severe isolated TBI patientsagreement %: 90, strong recommendation
  • Recommendation 9We recommend maintaining platelet (PLT) count > 75.000/mm3 in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)agreement %: 92, strong recommendation
  • Recommendation 10We recommend maintaining prothrombin time (PT)/activated partial thromboplastin time (aPTT) value < 1.5 the normal control in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)agreement %: 90, strong recommendation
  • Recommendation 12We recommend utilization of point-of-care (POC) tests [i.e., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)], if available, to optimize coagulation function in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring)agreement %: 75.6, weak recommendation
  • Recommendation 13We are unable to recommend the routine use of specific anti-seizure drugs in salvageable severe TBI patients presenting with seizure observed clinically and/or with electroencephalogram (EEG)agreement %: 65.9, no recommendation
  • Recommendation 22We recommend maintaining hemoglobin (Hb) level > 7 g/dl in severe TBI patientsagreement %: 95, strong recommendation
  • Recommendation 24We recommend maintaining an arterial partial pressure of carbon dioxide (PaCO2) of 35–38 mmHg in severe TBI patientsagreement %: 90, strong recommendation
  • Recommendation 25We recommend maintaining a serum sodium (Na) level of 140–145 mEq/l in severe TBI patientsagreement %: 90, strong recommendation

Airway, respiratory, hemodynamic, electrolytes and temperature management

  • Arterial hypotension (SAP < 90 mmHg), similar to hypoxia, has been associated with worse neurological outcomes in TBI [30]. In this regard, the Brain Trauma Foundation (BTF) guidelines recommend maintaining SAP at 100 mmHg for patients 50–69 years old or 110 mmHg or above for patients 15–49 or > 70 years old [17]. The European guidelines regarding the management of major hemorrhage and coagulopathy in polytrauma patients recommend maintaining MAP ≥ 80 mmHg in the case of severe TBI (grade 1C) [10]. Considering the above, we recommend maintaining SAP > 110 mmHg or MAP > 80 mmHg in severe isolated TBI patients. In the case of invasive ABP monitoring, we suggest that the arterial transducer should be zeroed at the level of the tragus according to the joint position statement by the councils of the Neuroanaesthesia and Critical Care Society of Great Britain and Ireland (NACCS) and the Society of British Neurological Surgeons (SBNS) [31]. About this, some panelists have expressed concerns. Specifically, zeroing the transducer at the level of the tragus and maintaining head of the bed elevated at 30°–45° (to facilitate brain venous drainage) could result in higher ABP values respect to zeroing made at the level of the heart. This is an interesting aspect requiring further research.

Abstract

Background: Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care.

Methods: A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted.

Results: A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided.

Conclusions: This consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13017-022-00468-2.

Contents of the original publication

The section headings of the original.

  • Background
  • Methods
  • Results
  • Recommendation 1
  • Recommendation 2
  • Recommendation 3
  • Recommendation 4
  • Recommendation 5
  • Recommendation 6
  • Recommendation 7
  • Recommendation 8
  • Recommendation 9
  • Recommendation 10
  • Recommendation 11
  • Recommendation 12
  • Recommendation 13
  • Recommendation 14
  • Recommendation 15
  • Recommendation 16
  • Recommendation 17
  • Recommendation 18
  • Recommendation 19
  • Recommendation 20
  • Recommendation 21
  • Recommendation 22
  • Recommendation 23
  • Recommendation 24
  • Recommendation 25
  • Recommendation 26
  • Recommendation 27
  • Recommendation 28
  • Discussion
  • Transfer to the HUB center
  • Airway, respiratory, hemodynamic, electrolytes and temperature management
  • Coagulation management
  • Neuromonitoring
  • Brain-focused therapy
  • Notes on the use of the current consensus
  • Conclusions

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