operativemanagements are based on the results of the primary and the secondary
surveys.
a. Airway : in the setting of TBI, airway management is performed with
particular attention to changes in mean arterial pressure MAP, ICP, arterial oxygen tension PaO
2
, arterial carbon dioxide tension PaCO
2
and cervical stability.
i. Indications for intubation include inability to protect the airway, difficulty with oxygenation or ventilation, shock, a GCS score 9, and
rapid neurologic deterioritation ii. Manual inline stabilization MILS
iii. Rapid squence induction RSI iv. Induction agent that can be used are propofol, thiopental and
etomidate. v. Several neuromuscular blocking drugs are appropriate for TBI such as
succinylcholine, rocuronium and mivacurium.
vi. As with all intubations, airway manager should consider awake- topical intubation if they are uncertain about their ability to establish
an airway quickly and safely. vii. Lidocaine IV
viii. Laryngeal mask airway LMA devices are useful backup tools for ventilation and intubation. Surgical airway techniques, such as
cricothyroidotomy and tracheostomy are also backup methods for intubation.
ix. Endotracheal intubation must be confirmed by physical examinaton plus a method for CO
2
detection such as colorimetric or continous capnography.
x. Chest x-ray are useful for verification of endotracheal tube positionas well as identificationof associated chest pathology such as
pneumothorax, lung contusion, and pulmonary edema.
b. Breathingventilation
i. High-flow oxygen is provided as supplement to all patients before intubation to prevent hypoxia and provide sufficient apneic time in
case further RSI is needed. ii. Oxygen saturation should be maintained above level now concidered
acceptable for patients who have acute respiratory distress syndome. iii. Positive-pressure ventilation is provided as needed to maintain
adequate ventilation and oxygenation. iv. The PaCO
2
should be kept at normocarbia v. Sedation : The ideal sedative drug in TBI should have rapid onset and
offset, anticonvulsant properties, and favorable effects on CPP. vi. Analgesia and blunting of stimulation associated with the endotracheal
tube can be achieved with opioids
c. Circulation: Systemic hypotension is one of the major contributor to poor
