Picetti et al. World Journal of World Journal of Emergency Surgery 2023, 18(1):5 https://doi.org/10.1186/s13017-022-00468-2 Emergency Surgery RESEARCH Open Access 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) Edoardo Picetti1*, Fausto Catena2, Fikri Abu‑Zidan3, Luca Ansaloni4, Rocco A. Armonda5,6, Miklosh Bala7, Zsolt J. Balogh8, Alessandro Bertuccio9, Walt L. Biffl10, Pierre Bouzat11, Andras Buki12, Davide Cerasti13, Randall M. Chesnut14,15,16, Giuseppe Citerio17,18, Federico Coccolini19, Raul Coimbra20, Carlo Coniglio21, Enrico Fainardi22, Deepak Gupta23, Jennifer M. Gurney24,25, Gregory W. J. Hawryluk26, Raimund Helbok27, Peter J. A. Hutchinson28, Corrado Iaccarino29, Angelos Kolias30,31, Ronald W. Maier32, Matthew J. Martin33, Geert Meyfroidt34,35, David O. Okonkwo36, Frank Rasulo37, Sandro Rizoli38, Andres Rubiano39, Juan Sahuquillo40, Valerie G. Sams41, Franco Servadei42,43, Deepak Sharma44, Lori Shutter45, Philip F. Stahel46, Fabio S. Taccone47, Andrew Udy48, Tommaso Zoerle49,50, Vanni Agnoletti51, Francesca Bravi52, Belinda De Simone53, Yoram Kluger54, Costanza Martino55, Ernest E. Moore56, Massimo Sartelli57, Dieter Weber58 and Chiara Robba59,60 Abstract Background Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hos‑ pital 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 immedi‑ ate 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 recommen‑ dations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. *Correspondence: Edoardo Picetti edoardopicetti@hotmail.com Full list of author information is available at the end of the article © The Author(s) 2023, corrected publication 2023. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 2 of 12 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. Keywords Traumatic brain injury, Management, Transfer, Hub, Spoke Background voting members, ambiguities and inconsistencies in the Traumatic brain injury (TBI) is a leading cause of mor- questionnaire were identified and corrected, generating tality and disability worldwide [1–4]. Severe TBI patients a refined question set for subsequent voting rounds. We often require emergency neurosurgery (i.e., to remove used an iterative approach; members were informed of post-traumatic mass lesions) and/or invasive neuromoni- the degree of consensus reached on the initial question toring (i.e., to guide and personalize therapy) to improve round and asked to reconsider agreement or disagree- mortality and neurological outcomes [1, 3, 5]. Consider- ment. Then, based on the answers collected in the third ing the above, severe TBI patients should be primarily stage, statements for practical advice were proposed. admitted to a hub trauma center (hospital with neurosur- The objective was to reach consensus, not necessarily gical capabilities) to allow immediate delivery of appro- unanimity. priate care in a specialized environment [1, 3, 6–8]. The analysis of voting results was performed by a non- Sometimes, severe TBI patients are admitted to a spoke voting experienced methodologist (CR). A decision rule hospital (hospital without neurosurgical capabilities) was predefined to ascertain the degree of consensus due to geographic or patient-related factors [9]. There is required to provide a recommendation. Statements were currently a paucity of available literature regarding the classified as strong recommendation, weak recommen- optimal management of severe isolated TBI patients at a dation and no recommendation when > 85%, 75–85% spoke hospital [3]. The specific aim of this consensus is and < 75% of votes were in favor, respectively. to provide recommendations on the early management In this consensus, we specifically refer to isolated severe of severe isolated TBI patients admitted to a spoke hos- TBI patients [Glasgow Coma Scale (GCS) score ≤ 8] pital and during the transfer to a hub hospital. Precisely, admitted to a spoke non-rural hospital of a high-income we refer to patients admitted to an urban spoke hospi- country with the availability of: ICU, OR and whole-body tal without neurosurgical capabilities in a high-income CT scanner. country with the availability of an intensive care unit (ICU), operating room (OR) and computed tomography Results (CT) scan. In the case of severe TBI with extra-cranial The consensus provided 25 recommendations (Table 1): lesions or admitted to hospitals with limited resources, 22 were strong recommendations, endorsed by more readers can refer to several published articles/guidelines than 85% of participants, while 3 were weak recommen- for initial management [10–14]. dations, supported by 75–85%. The consensus flowchart is reported in Fig. 1. We were unable to reach consensus Methods for 3 statements. The consensus recommendations are The multidisciplinary consensus panel was composed of listed below with the percentage of agreement. anesthesiologists/intensivists/neurointensivists (n = 13), neurosurgeons (n = 14), neuroradiologists (n = 2) and Recommendation 1 acute care surgeons (n = 13) with expertise in TBI care We recommend that all salvageable (i.e., patients who (see Additional file 1: Appendix 1). Following a non- may recover, at least to some extent, with appropriate systematic review of the literature, the steering com- treatment) severe isolated TBI patients needing or at risk mittee (EP, CR and FC) identified the main domains to of needing neurosurgery [i.e., for surgical mass lesion discuss and generated a list of questions to be addressed and/or intracranial pressure (ICP) monitoring] admitted by the panel. Three subsequent online questionnaires to a spoke center should be rapidly transferred to a hub were administered between July and September 2022. center after hemodynamic and respiratory stabilization The initial list of statements (28) was formulated and (agreement %: 97.6, strong recommendation). distributed to the panelists 1 week prior to every Delphi round to allow modifications or additional statements. Recommendation 2 The modified interactive Delphi process was conducted We recommend the utilization of a telemedicine service using online tools. After a preliminary round, based on for rapid digital image transfer from the spoke to the hub the initial answers and on comments/suggestions by the center (agreement %: 92.7, strong recommendation). Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 3 of 12 Table 1 List of consensus recommendations N Recommendation Level 1 We recommend that all salvageable (i.e., patients who may recover, at least to some extent, with appropriate treatment) severe iso‑ Strong recommendation lated 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 stabilization 2 We recommend the utilization of a telemedicine service for rapid digital image transfer from the spoke to the hub center Strong recommendation 3 We recommend, before and during transfer from the spoke to the hub center, a continuous and clear collaboration/communication Strong recommendation (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.) 4 We recommend sedation, intubation and mechanical ventilation for the transfer of all severe TBI patients Strong recommendation 5 We recommend that the transfer of severe TBI patients should be performed by appropriately trained and certified critical care trans‑ Weak recommendation port personnel with experience in advanced airway management/life support strategies and basic knowledge of neurocritical care (i.e., medical management of cerebral swelling, herniation) 6 We recommend that severe salvageable TBI patients with signs/elevated risk of herniation and need for neurosurgery (brain CT scan Strong recommendation already done in spoke hospital with neurosurgical consultation) should be directly transported form the spoke center to the OR at the hub center 7 We recommend, in severe TBI patients needing transfer to the hub center, an invasive monitoring of ABP in addition to the standard Weak recommendation cardiorespiratory monitoring (ECG, HR, ­SpO2 and ­ETCO2) 8 We recommend maintaining SAP > 110 mmHg or mean arterial pressure MAP > 80 mmHg* in severe isolated TBI patients Strong recommendation *In the case of invasive ABP monitoring, the arterial transducer should be zeroed at the level of the tragus 9 We recommend maintaining PLT count > 75.000/mm3 in all salvageable severe TBI patients at risk of needing neurosurgery (including Strong recommendation ICP monitoring) 10 We recommend maintaining PT/aPTT value < 1.5 the normal control in all salvageable severe TBI patients at risk of needing neurosur‑ Strong recommendation gery (including ICP monitoring) 11 We recommend early reversal of anticoagulant/antiplatelets agents, in all salvageable severe TBI patients at risk of needing neurosur‑ Strong recommendation gery (including ICP monitoring) 12 We recommend utilization of POC tests (i.e., TEG and ROTEM), if available, to optimize coagulation function in all salvageable severe Weak recommendation TBI patients at risk of needing neurosurgery (including ICP monitoring) 13 We are unable to recommend the routine use of specific anti-seizure drugs in salvageable severe TBI patients presenting with seizure No recommendation observed clinically and/or with EEG 14 We recommend performing serial neurologic evaluations (GCS + pupil examination) in the spoke center and during transfer to the Strong recommendation hub center to detect neurologic deterioration in patients without signs of intracranial hypertension 15 We recommend against discontinuation of sedation to obtain a reliable neurological evaluation in patients with radiological signs Strong recommendation 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 useful 16 We are unable to recommend use of brain ultrasonography (i.e., optic nerve sheath diameter, cerebral blood flow waveform analysis, No recommendation etc.), in the presence of skilled operators, as a reliable screening non-invasive tool for detection of intracranial hypertension in the spoke center 17 We are unable to recommend use of automated pupillometry, if available, as a reliable screening non-invasive tool for detection of No recommendation intracranial hypertension in the spoke center 18 We recommend that performance of brain ultrasonography and/or automated pupillometry, if utilized in the spoke center, should Strong recommendation not significantly delay the patient’s transfer 19 We recommend that severe isolated TBI patients should be maintained with a head of the bed elevated at 30°–45° to facilitate brain Strong recommendation venous drainage in the spoke center and during transfer to the hub center 20 We recommend that in severe TBI patients, the head should be maintained in the midline avoiding compression of the neck veins in Strong recommendation the spoke center and during transfer to the hub center 21 We recommend avoiding core body temperature > 37.5 °C and to aim for normothermia in severe TBI patients Strong recommendation 22 We recommend maintaining Hb level > 7 g/dl in severe TBI patients Strong recommendation 23 We recommend maintaining ­SpO2 > 94% in severe TBI patients Strong recommendation 24 We recommend maintaining a P ­ aCO2 of 35–38 mmHg in severe TBI patients Strong recommendation 25 We recommend maintaining a serum Na level of 140–145 mEq/l in severe TBI patients Strong recommendation 26 We recommend osmotherapy as a therapeutic maneuver to be utilized in patients with signs of intracranial hypertension/brain Strong recommendation herniation awaiting emergent neurosurgery 27 We recommend short-term hyperventilation as a therapeutic maneuver that should be utilized only in patients with signs of brain Strong recommendation herniation awaiting emergent neurosurgery 28 We recommend an increase in sedation, while maintaining an acceptable ABP, as a therapeutic maneuver that should be utilized in Strong recommendation the management of patients with signs of brain herniation awaiting emergent neurosurgery TBI, traumatic brain injury; ICP, intracranial pressure; ICU, intensive care unit; OR, operating room; CT, computed tomography; GCS, Glasgow coma scale; ABP, arterial blood pressure; ECG, electrocardiogram; HR, heart rate; ­SpO2, peripheral oxygen saturation; ­ETCO2, end-tidal carbon dioxide; MAP, mean arterial pressure; SAP, systolic arterial pressure; PLT, platelet; PT, prothrombin time; aPTT, activated partial thromboplastin time; POC, point-of-care; TEG, thromboelastography; ROTEM, rotational thromboelastometry; EEG, electroencephalogram; Hb, hemoglobin; ­PaCO2, arterial partial pressure of carbon dioxide; Na, sodium Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 4 of 12 Fig. 1 Consensus flowchart. (1)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.). (2)Patients with signs/elevated risk of herniation and need for emergent neurosurgery with brain CT scan already done in spoke hospital with neurosurgical consultation. (3)In the case of invasive ABP monitoring, the arterial transducer should be zeroed at the level of the tragus. (4) At risk of needing neurosurgery (including ICP monitoring). (5)Serial examination in the spoke hospital and during transfer to the hub center to detect neuro-worsening. We recommend against the 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 useful. (6)Also during transfer. Abbreviations TBI, traumatic brain injury; ICP, intracranial pressure; ICU, intensive care unit; OR, operating room; CT, computed tomography; GCS, Glasgow coma scale; ABP, arterial blood pressure; ECG, electrocardiogram; HR, heart rate; ­SpO2, peripheral oxygen saturation; ­ETCO2, end-tidal carbon dioxide; MAP, mean arterial pressure; SAP, systolic arterial pressure; PLT, platelet; PT, prothrombin time; aPTT, activated partial thromboplastin time; POC, point-of-care; TEG, thromboelastography; ROTEM, rotational thromboelastometry; EEG, electroencephalogram; Hb, hemoglobin; P ­ aCO2, arterial partial pressure of carbon dioxide; Na, sodium; CC, critical care Recommendation 3 certified critical care transport personnel with experience We recommend, before and during transfer from the in advanced airway management/life support strategies spoke to the hub center, a continuous and clear col- and basic knowledge of neurocritical care (i.e., medical laboration/communication (i.e., check for availability management of cerebral swelling, herniation) (agreement of ICU bed/OR, significant clinical deterioration dur- %: 80.5, weak recommendation). ing transfer, etc.) between different medical specialties (anesthesiology/intensive care/neurocritical care, neu- Recommendation 6 rosurgery, neuroradiology, trauma surgery, etc.) (agree- We recommend that severe salvageable TBI patients with ment %: 92.7, strong recommendation). signs/elevated risk of herniation and need for neurosur- gery (brain CT scan already done in spoke hospital with Recommendation 4 neurosurgical consultation) should be directly trans- We recommend sedation, intubation and mechani- ported form the spoke center to the OR at the hub center cal ventilation for the transfer of all severe TBI patients (agreement %: 85.1, strong recommendation). (agreement %: 95, strong recommendation). Recommendation 7 Recommendation 5 We recommend, in severe TBI patients needing trans- We recommend that the transfer of severe TBI patients fer to the hub center, an invasive monitoring of arte- should be performed by appropriately trained and rial blood pressure (ABP) in addition to the standard Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 5 of 12 cardiorespiratory monitoring [electrocardiogram (ECG), Recommendation 15 heart rate (HR), peripheral oxygen saturation (­SpO2) and We recommend against discontinuation of sedation to end-tidal carbon dioxide ­(ETCO2)] (agreement %: 82.9, obtain a reliable neurological evaluation in patients with weak recommendation). radiological signs of intracranial hypertension (i.e., mid- line shift, compression of the basal cisterns, sulcal efface- Recommendation 8 ment, etc.). In this scenario, only pupil examination, We recommend maintaining systolic arterial pres- especially during the transfer, would be useful (agree- sure (SAP) > 110 mmHg or mean arterial pressure ment %: 95, strong recommendation). (MAP) > 80 mmHg* in severe isolated TBI patients (agreement %: 90, strong recommendation). Recommendation 16 * In the case of invasive ABP monitoring, the arterial We are unable to recommend use of brain ultrasonog- transducer should be zeroed at the level of the tragus. raphy (i.e., optic nerve sheath diameter, cerebral blood flow waveform analysis, etc.), in the presence of skilled Recommendation 9 operators, as a reliable screening non-invasive tool for We recommend maintaining platelet (PLT) count > 75.000/ detection of intracranial hypertension in the spoke center mm3 in all salvageable severe TBI patients at risk of need- (agreement % 61, no recommendation). ing neurosurgery (including ICP monitoring) (agreement %: 92, strong recommendation). Recommendation 17 We are unable to recommend use of automated pupil- Recommendation 10 lometry, if available, as a reliable screening non-invasive We recommend maintaining prothrombin time (PT)/ tool for detection of intracranial hypertension in the activated partial thromboplastin time (aPTT) value < 1.5 spoke center (agreement %: 63, no recommendation). the normal control in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitor- Recommendation 18 ing) (agreement %: 90, strong recommendation). We recommend that performance of brain ultrasonog- raphy and/or automated pupillometry, if utilized in the Recommendation 11 spoke center, should not significantly delay the patient’s We recommend early reversal of anticoagulant/antiplate- transfer (agreement %: 90, strong recommendation). lets agents, in all salvageable severe TBI patients at risk of needing neurosurgery (including ICP monitoring) Recommendation 19 (agreement %: 90, strong recommendation). We recommend that severe isolated TBI patients should be maintained with a head of the bed elevated at 30°–45° Recommendation 12 to facilitate brain venous drainage in the spoke center We recommend utilization of point-of-care (POC) tests and during transfer to the hub center (agreement %: 92.7, [i.e., thromboelastography (TEG) and rotational throm- strong recommendation). boelastometry (ROTEM)], if available, to optimize coag- ulation function in all salvageable severe TBI patients at Recommendation 20 risk of needing neurosurgery (including ICP monitoring) We recommend that, in severe TBI patients, the head (agreement %: 75.6, weak recommendation). should be maintained in the midline avoiding compression of the neck veins in the spoke center and during transfer to Recommendation 13 the hub center (agreement %: 97.7, strong recommendation). We are unable to recommend the routine use of specific anti-seizure drugs in salvageable severe TBI patients Recommendation 21 presenting with seizure observed clinically and/or with electroencephalogram (EEG) (agreement %: 65.9, no We recommend avoiding core body temperature > 37.5 °C recommendation). and to aim for normothermia in severe TBI patients (agreement %: 95, strong recommendation). Recommendation 14 We recommend performing serial neurologic evalua- Recommendation 22 tions (GCS + pupil examination) in the spoke center and We recommend maintaining hemoglobin (Hb) level > 7 g/ during transfer to the hub center to detect neurologic dl in severe TBI patients (agreement %: 95, strong deterioration in patients without signs of intracranial recommendation). hypertension (agreement %: 95, strong recommendation). Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 6 of 12 Recommendation 23 bed/OR, significant clinical deterioration during transfer, We recommend maintaining S ­ pO2 > 94% in severe TBI etc.) should occur between different medical specialties patients (agreement %: 87.8, strong recommendation). (anesthesiology/intensive care/neurocritical care, neuro- surgery, neuroradiology, trauma surgery, etc.). The above- mentioned aspects, in addition to be in accordance with Recommendation 24 published guidelines [21], are of paramount importance We recommend maintaining an arterial partial pressure to ensure “high-quality” TBI perioperative care [3]. In of carbon dioxide (­ PaCO2) of 35–38 mmHg in severe TBI particular, severe salvageable TBI patients with signs/ patients (agreement %: 90, strong recommendation). elevated risk of herniation and need for neurosurgery (brain CT scan already done in spoke hospital with neu- Recommendation 25 rosurgical consultation) could benefit from direct trans- We recommend maintaining a serum sodium (Na) level port from the spoke center to the OR in the hub center. of 140–145 mEq/l in severe TBI patients (agreement %: This requires not only an excellent coordination between 90, strong recommendation). all involved medical specialties, but review of CT scans and laboratories prior to the patient arrival; this concept is similar to what is applied in some trauma centers in the Recommendation 26 treatment of severely injured patients at increased risk We recommend osmotherapy as a therapeutic maneuver for requiring lifesaving interventions or emergency sur- to be utilized in patients with signs of intracranial hyper- gery [22]. Some panelists suggested that patients requir- tension/brain herniation awaiting emergent neurosur- ing urgent surgery should be transferred irrespective of gery (agreement %: 95, strong recommendation). the availability of an ICU bed. This is an interesting and debated point. A TBI patient needing evacuation of a critical mass lesion could be transferred to the nearest Recommendation 27 neurosurgical unit for an operation regardless of ICU bed We recommend short-term hyperventilation as a thera- availability; this problem could be arranged in the post- peutic maneuver that should be utilized only in patients surgical phase. with signs of brain herniation awaiting emergent neuro- Telemedicine, allowing the transfer of radiological surgery (agreement %: 90, strong recommendation). images by a web-based software, facilitates neurosurgical consultation between hospitals and, preventing unneces- Recommendation 28 sary transfers, is life/time-saving and cost-effective [23, We recommend an increase in sedation, while maintain- 24]. Telemedicine should be encouraged in this setting ing an acceptable ABP, as a therapeutic maneuver that as has been already done for aneurysmal subarachnoid should be utilized in the management of patients with hemorrhage (aSAH) patients [25]. Severe TBI patients signs of brain herniation awaiting emergent neurosurgery can also deteriorate at any time during the transfer (i.e., (agreement %: 95, strong recommendation). neuro-worsening, hemodynamic instability, etc.). As also suggested in other guidelines [21], these patients should Discussion be accompanied during the transport by a physician with Transfer to the HUB center expertise in airway management, life support strategies All salvageable severe isolated TBI patients, needing or at and basic knowledge of neurocritical care. Some pan- risk of needing neurosurgery (i.e., for surgical mass lesion elists pointed out that worldwide there can be different and/or ICP monitoring) [15–19], should be transported systems regarding the transfer of critical care patients to a hub center (hospital with neurosurgical capabilities). (i.e., paramedics). Regarding these possible organiza- This is important not only for the surgical aspect but also tional differences, the transfer should be carried out by to facilitate appropriate care in a specialized environment appropriately trained and certified critical care transport [1, 3, 6–8]. Moreover, a recent systematic review and personnel to ensure adequate quality of care. Practical meta-analysis showed that neurocritical care services are protocols between hub and spoke hospitals should be associated with improved survival and functional out- encouraged to facilitate the transfer. In this regard, a pre- comes in critically ill adults with brain injury [20]. pared and shared checklist could be helpful. The transfer, as recommended also by recent guidelines Considering the above-mentioned points, adequate [21], should be performed after cardiorespiratory stabili- cardiorespiratory monitoring (ECG, HR, ABP, ­SpO2 and zation. Furthermore, before and during transfer from the ­ETCO2) seems to be fundamental for the safety of the spoke to the hub center, a continuous and clear collabo- patients during the transfer [21]. Invasive ABP moni- ration/communication (i.e., check for availability of ICU toring, being accurate and continuous, is preferable Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 7 of 12 (especially in unstable severe TBI patients). However, values respect to zeroing made at the level of the heart. placement of an arterial line should not excessively delay This is an interesting aspect requiring further research. the patient transfer, and non-invasive ABP (NIABP) Pending the results of ongoing trials [“Transfusion monitoring should be considered as a valid alternative in Strategies in Acute Brain-Injured Patients (TRAIN)” cases of difficult arterial access. study (NCT02968654) and the “HEMOglobin transfu- sion threshold in Traumatic brain Injury OptimizatioN: Airway, respiratory, hemodynamic, electrolytes The HEMOTION Trial” (NCT03260478)] and according and temperature management to guidelines/consensus [10, 29], we recommend main- Severe isolated TBI patients require tracheal intubation taining Hb level > 7 g/dl in severe isolated TBI patients. (to protect the airway) and mechanical ventilation (to Hyponatremia can be detrimental for TBI patients at optimize gas exchange) [26]. Tracheal intubation needs to risk of intracranial hypertension and should be avoided be performed carefully with adequate analgesia and seda- [29, 32, 33]. In this regard, we recommend maintaining tion to avoid arterial desaturation, increase in ABP exac- serum Na in the upper limit of the normal range. erbating pre-existing intracranial hematoma or severe Fever is a dangerous secondary insult for the injured hypotension with associated cerebral hypoperfusion [21]. brain associated with worse neurological outcome [34]. Some panelists suggested the utilization of drugs with a The optimal threshold to start antipyretics therapy in TBI short half-life and easily titratable to allow a reliable neu- has not yet been established [35]. Considering the gradi- rological examination. ent between core and brain temperature (brain > core) Episodes of ­ SpO2 < 90%, being associated with [36], we recommend avoiding core body tempera- increased mortality and worse neurological outcome ture > 37.5 °C and to aim for normothermia. in TBI, should be avoided [26, 27]. Cerebral perfusion is influenced by ­PaCO2 level, and ventilation should be Coagulation management adjusted to avoid hypo/hypercapnia [26, 28]. According Coagulopathy, associated with TBI or with previously to recent consensus conferences [26, 29], we recommend administered drugs, is frequently encountered after head maintaining ­SpO2 > 94% and a ­PaCO2 of 35–38 mmHg. injury, and the consequent progression of intracranial We are aware that optimal respiratory values have yet mass lesions is often associated with unfavorable neuro- to be determined in this setting. Moreover, the absence logical outcome [37–40]. The rapid correction of trauma- of invasive neuromonitoring (generally available in the or medication-induced coagulopathy is very important, referral center) prevents the individualization (person- especially for patients needing urgent neurosurgical alization) of care. ­ETCO2 values should be adapted fre- procedures. Whether the management of hemostatic quently with data from arterial blood gas analysis. abnormalities after TBI can protect against secondary Arterial hypotension (SAP < 90 mmHg), similar to brain injury and improve neurological outcomes remains hypoxia, has been associated with worse neurological elusive [41]; no specific guidelines regarding coagula- outcomes in TBI [30]. In this regard, the Brain Trauma tion management in TBI patients have been published to Foundation (BTF) guidelines recommend maintain- date. Basic coagulation parameters suggested for neuro- ing SAP at 100 mmHg for patients 50–69 years old or surgery are: PLT count > 75.000 or 100.000/mm3 and PT/ 110 mmHg or above for patients 15–49 or > 70 years old aPTT < 1.5 the normal control values [10, 42, 43]. The [17]. The European guidelines regarding the management utilization of POC tests, such as TEG and ROTEM, may of major hemorrhage and coagulopathy in polytrauma be useful to personalize therapy in this setting and in the patients recommend maintaining MAP ≥ 80 mmHg in case of utilization of antiplatelets drugs and/or direct the case of severe TBI (grade 1C) [10]. Considering the oral anticoagulants (DOACs) [44]. Our recommenda- above, we recommend maintaining SAP > 110 mmHg or tions are in agreement with the above. We are aware that MAP > 80 mmHg in severe isolated TBI patients. In the POC tests are not available worldwide. Their use can be case of invasive ABP monitoring, we suggest that the considered, but without significantly delay the transfer. arterial transducer should be zeroed at the level of the Some panelists suggested a PLT count > 100.000/mm3 tragus according to the joint position statement by the compared with > 75.000 ­mm3; in this regard, the optimal councils of the Neuroanaesthesia and Critical Care Soci- cut-off for TBI patients at risk of needing neurosurgery ety of Great Britain and Ireland (NACCS) and the Soci- has yet to be established. According to some panelists, ety of British Neurological Surgeons (SBNS) [31]. About reversal of antiplatelets/anticoagulants drugs should be this, some panelists have expressed concerns. Specifi- started immediately prior to neurosurgery and for oth- cally, zeroing the transducer at the level of the tragus and ers, optimization of coagulation should not delay the maintaining head of the bed elevated at 30°–45° (to facili- transfer too much and could even be done “en route.” We tate brain venous drainage) could result in higher ABP suggest readers to refer to the “Guideline for Reversal Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 8 of 12 of Antithrombotics in Intracranial Hemorrhage” of the well-powered studies on this topic. The possible utiliza- Neurocritical Care Society (NCS) and the Society of Crit- tion of brain ultrasonography and automated pupillom- ical Care Medicine (SCCM) published in 2016 with the etry, by experienced operators, should not significantly aim to provide timely and evidence-based reversal strate- delay the patient’s transfer. gies for the care of patients with antithrombotic-associ- ated intracranial hemorrhage [44]. Brain‑focused therapy The maintenance of the head of a severe isolated TBI patients in the midline, avoiding compression of the neck Neuromonitoring veins, and with a bed elevated at 30°–45° to facilitate ICP monitoring is usually not available in spoke cent- brain venous drainage are basic maneuvers in the neuro- ers and during transfer to hub centers. However, differ- critical care setting [29]. These should always be applied ent tools can help us to estimate the risk of intracranial with adequate spine precautions. Some panelists empha- hypertension. A basic neurological evaluation, including sized as some patients may require a lower bed elevation; GCS and pupil examination (size and reaction), is very this, considering what has been said previously for the helpful to identify neurological deterioration associated zeroing of the arterial transducer in the case of invasive with an increase of ICP [5, 45]. The motor response is the ABP monitoring, could lead to a reduced use of vasopres- most easily evaluable component of the GCS (especially sors for maintaining the blood pressure target. in conditions where verbal response and eye opening can Osmotherapy (i.e., mannitol or hypertonic saline) is be difficult to obtain, as in the case of tracheal intubation, effective in the rapid control of ICP through a reduc- facial injuries, etc.) [5, 45]. Pupillary shape/diameter and tion in blood viscosity and an increase in plasma osmo- reactivity to light should be carefully evaluated [5, 46, 47]. larity [53]. Currently, adequately powered randomized These evaluations are essential before tracheal intubation controlled studies clearly showing the superiority of and sedation. However, discontinuation of sedation to mannitol compared to hypertonic saline are lacking. obtain a reliable neurological evaluation can be danger- Considering the diuretic effect of mannitol, hypertonic ous in patients with radiological signs of increased ICP saline is a potentially reasonable choice in cases of hypo- [48]. Although not specific, certain CT radiological signs volemia [29]. Moreover, the early utilization of mannitol, are suggestive of intracranial hypertension such as the but not hypertonic saline, seems to be associated with compression of the basal cisterns, midline shift and sulcal increased incidence of acute kidney injury [54]. effacement [49, 50]. Hypocapnia associated with hyperventilation results Brain ultrasonography, when performed by a skilled in cerebral vasoconstriction with a reduction in cer- operator, can estimate intracranial hypertension by the ebral blood flow (CBF), cerebral blood volume and evaluation of optic nerve sheath diameter (ONSD), pul- consequently ICP [28]. This temporary effect is associ- satility index (PI), etc. [51]. ated with the risk of development of cerebral ischemia Automated pupillometry accurately measures the pupil [55]. Profound hypocapnia is not recommended as a size and several dynamic variables such as pupillary con- prophylactic maneuver but could be utilized briefly for striction, latency and constriction/dilation velocity [51]. patients awaiting emergent neurosurgery [17, 26]. The integration of the latter into an algorithm provides Metabolic suppression with sedatives can be use- the Neurological Pupil index (NPi—values 0–5; patholog- ful in the control of intracranial hypertension but can ical < 3) [52]. Episodes of raised ICP are associated with increase the risk of hypotension [56, 57]. The reduc- a concomitant decrease of the NPi [52]. Considering the tion in blood pressure, observed in this scenario, above, we recommend performing serial neurologic eval- should be aggressively corrected. In this regard, keta- uations (GCS + pupil examination) in the spoke center mine could be a useful option, but more data are nec- and during transfer to the hub center to detect neuro- essary to confirm this [58]. worsening in the absence of radiological signs of intracra- Considering the above, in patients with signs of nial hypertension (i.e., midline shift, compression of the intracranial hypertension/brain herniation awaiting basal cisterns, sulcal effacement, etc.). In this scenario, emergent neurosurgery, we recommend osmotherapy, only pupillary evaluation (shape/diameter and reactivity short-term hyperventilation and an increase in seda- to light), especially during transfer, could be useful. We tion (ensuring an acceptable ABP). were unable to reach a consensus on the utilization of According to BTF guidelines [17], prophylactic phe- brain ultrasonography and automated pupillometry as a nytoin or valproate are not recommended for prevent- screening non-invasive tool for detection of intracranial ing late post-traumatic seizures (PTS) and phenytoin hypertension in the spoke center. This could be related, at is recommended to decrease the incidence of early the moment, to the absence of robust data deriving from Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 9 of 12 PTS (within 7 days of injury), when the overall benefit ETCO2 End-tidal carbon dioxide SAP Systolic arterial pressure is thought to outweigh the complications associated MAP Mean arterial pressure with such treatment (early PTS have not been associ- PLT Platelet ated with worse outcomes). Considering the above PT Prothrombin time aPTT Activated partial thromboplastin time and awaiting the results of the ongoing “Management POC Point-of-care of Seizure after Traumatic Brain Injury” (MAST) trial TEG Thromboelastography (NCT04573803), we were unable to provide any rec- ROTEM Rotational thromboelastometry EEG Electroencephalogram ommendations regarding seizure prophylaxis in severe Hb Hemoglobin isolated TBI patients. PaCO2 Arterial partial pressure of carbon dioxide Na Sodium aSAH Aneurysmal subarachnoid hemorrhage NIABP Non-invasive arterial blood pressure Notes on the use of the current consensus BTF Brain Trauma Foundation The aim of this consensus is to support clinicians’ deci- NACCS Neuroanaesthesia and Critical Care Society of Great Britain and Ireland sion making in the early management of isolated severe SBNS Society of British Neurological Surgeons TBI patients admitted to a hospital without neurosur- TRAIN Transfusion Strategies in Acute Brain-Injured Patients gical capabilities. The included statements are created DOACs Direct oral anticoagulants NCS Neurocritical Care Society to assist the physician’s clinical judgment, which is nec- SCCM Society of Critical Care Medicine essary to provide appropriate (personalized) therapy. ONSD Optic nerve sheath diameter Considering the lack of high-quality studies in this set- PI Pulsatility index NPi Neurological Pupil index ting, we adopted a modified Delphi approach involv- CBF Cerebral blood flow ing experts from different countries worldwide; this PTS Post-traumatic seizures approach is less rigorous than evidence-based guide- MAST Management of Seizure after Traumatic Brain Injury lines. However, we think that our methodology can provide useful recommendations for these challenging Supplementary Information clinical scenarios. The practice guidelines promulgated The online version contains supplementary material available at https://​doi.​ org/​10.​1186/​s13017-​022-​00468-2. in this work do not represent a standard of practice. They are suggested plans of care, based on the best avail- Additional file 1. Appendix 1. Consensus participants. able evidence and the consensus of experts, but they do not exclude other approaches as being within the stand- Acknowledgements ard of practice. Ultimately, responsibility for the results We would like to thank WSES for the support. of treatment rests with those who are directly engaged therein, and not with the consensus group. Author contributions EP, CR and FC have designed the study. CR has performed acquisition of data. CR has done the analysis and interpretation of data. EP, CR and FC have drafted Conclusions the article. All authors have revised it critically for important intellectual con‑ Future studies should be encouraged to improve clini- tent. All authors read and approval the final manuscript. cal outcomes for patients with severe TBI who do not Funding have immediate access to neurosurgical care. This None. international multidisciplinary consensus conference Availability of data and materials was aimed to provide practical recommendations to The datasets used and/or analyzed during the current study are available from deliver the best early possible care of severe isolated the corresponding author on reasonable request. TBI patients admitted to a spoke center (without neu- rosurgical capabilities) and during the transfer to the Declarations hub center (with neurosurgical capabilities). Ethics approval and consent to participate Abbreviations Not applicable. TBI Traumatic brain injury WSES World Society of Emergency Surgery Consent for publication ICU Intensive care unit Not applicable. OR Operating room CT Computed tomography Competing interests GCS Glasgow Coma Scale None to declare. ICP Intracranial pressure ABP Arterial blood pressure Author details 1 ECG Electrocardiogram Department of Anesthesia and Intensive Care, Parma University Hospi‑ HR Heart rate tal, Parma, Italy. 2 Department of General and Emergency Surgery, Bufalini SpO2 Peripheral oxygen saturation Hospital, Cesena, Italy. 3 The Research Office, College of Medicine and Health Picetti et al. World Journal of Emergency Surgery 2023, 18(1):5 Page 10 of 12 Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates. 4 Unit St Germain en Laye, Poissy, France. 54 Department of General Surgery, Rambam of General Surgery, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy. Health Care Campus, Haifa, Israel. 55 Department of Anesthesiology and Acute 5 Department of Neurosurgery, 71541MedStar Georgetown University Hospital, Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy. 56 Ernest Washington, DC, USA. 6 Department of Neurosurgery, 8405MedStar Washing‑ E Moore Shock Trauma Center at Denver Health, University of Colorado, ton Hospital Center, Washington, DC, USA. 7 Acute Care Surgery and Trauma Denver, CO, USA. 57 Department of Surgery, Macerata Hospital, Macerata, Unit, Department of General Surgery, Hadassah Medical Center and Faculty Italy. 58 Department of General Surgery, Royal Perth Hospital, The University of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, Jerusalem, Israel. of Western Australia, Perth, Australia. 59 Anesthesia and Intensive Care, San 8 Department of Traumatology, John Hunter Hospital, Hunter Medical Research Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Institute and University of Newcastle, Newcastle, NSW, Australia. 9 Department Italy. 60 Department of Surgical Sciences and Integrated Sciences, University of Neurosurgery, SS Antonio E Biagio E Cesare Arrigo Alessandria Hospital, of Genoa, Genoa, Italy. Alessandria, Italy. 10 Scripps Clinic Medical Group, La Jolla, CA, USA. 11 Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Université Received: 12 November 2022 Accepted: 1 December 2022 Grenoble Alpes, Grenoble, France. 12 Department of Neurosurgery, Faculty Published: 9 January 2023 of Medicine and Health, Örebro University, Örebro, Sweden. 13 Neuroradiol‑ ogy Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy. 14 Depart‑ ment of Neurological Surgery, University of Washington, Seattle, WA, USA. 15 Department of Orthopedics and Sports Medicine, University of Washington, References Seattle, WA, USA. 16 Department of Global Health, University of Washington, 1. 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