There is a flurry of activity - an early transfer from ER --> ICU has been initiated after basic workup in ER. A diagnosis of Traumatic Brain Injury (TBI) without any other internal organ injury from Trauma has been made.





As you run into the room, it seems you still were slow, the Fellow & Attending are already present at bedside.The pt is agitated has a hard neck collar in place and Nurses are having a hard time keeping him in bed. As always he was calm in ER (seems like ICU has this effect on Pt's). You are assigned to man the computer- pull up images, labs & interventions done in ER, record interventions being done currently & place orders.





Even your eyes can see some scattered white spots bilaterally on CT Head. GCS? someone shouts 9, Pupils ? - equal & reactive; BP appears to be on high side while there are some fluctuations in his oxygen status. Decision is made to Intubate. Neurosurgery also steps in & is waiting for the Pt to be intubated so he can place an EVD - to monitor his ICP.

Even this chaotic situation is a learning experience, instead of PowerPoint we are back to the golden old age of bedside Dry Erase Board & markers.





While a Glidescope is used to intubate the pt without removing the Neck collar, you & others get to know about TBI.





It seems TBI is a pretty expensive diagnosis with devastating effect on Pt's & their family. Even after survival there may be long term disability. MVA as a cause maybe decreasing, but falls from standing position in Elderly are increasing .

GCS is used to classify TBI into mild (13-15); Moderate (9-12) & Severe (3-9 ). CT scan Head is the exam of choice & there appears to be a Marshall Scale & a Rotterdam Scale to classify the severity.

Seems like there is a Primary Insult that starts the ball rolling & there are some Secondary Insults which either keep the ball rolling or even accelerate it.





Search for a magic bullet to decrease debility & improve prognosis & mortality is ongoing with failures of many promising treatment options. Recently however it seems there was a successful trial & you are asked to order Tranexamic Acid (TA).

It appears TBI results in coagulopathy & and can result in increased fibrinolysis. This can lead to new bleeding even a few hours after minor injury while the original bleeding can worsen. TA - it appears, works by inhibiting fibrinolysis & stops bleeding in the early hours of TBI.





CRASH-3 in Lancet Nov 9th 2019; pp:1713-1723 was a Multicenter trial across 27 countries. 12,000+ Pt's were randomized. Initially Tranexamic Acid (TA) could be given within 8 hrs however it was later changed to 3 hrs as new evidence became available. 4649 Pt's received TA within 3 hrs while 4553 received Placebo.

Head Injury related deaths at 28 days were 18.5% in TA grp vs 19.8% in Placebo. When Pt's with GCS of 3 or nonreactive pupils were excluded it still favored TA (12.5% VS 14%).The results were even more impressive in Mild to moderate cases of TBI (GCS 9-15) - 5.8% VS 7.5%.

Side effects of Seizure (3.2% vs 3%) & Vascular Thrombosis (1.6% vs 1.6%) were similar. The disability in the 2 grps was also similar despite more survivals.





So what Now: This remarkable study is likely going to change the standard of care.How many times have we observed Pt's with GCS 13-15 with minor contusions in ICU, doing serial Neurochecks only. The study showed that most bang for the buck is these mild to moderate TBI cases.

Time being an essence - use TA within 3 hours especially in Mild to Moderate TBI - 1gm IV load over 10 minutes followed by 1gm IV over 8 hrs as given in study.