European Journal of Trauma and Emergency Surgery (2017) 43:729–730
Focus on traumatic brain injury
Published online: 24 November 2017
© Springer-Verlag GmbH Germany 2017
Almost every paper on brain trauma starts with the state-
ment that traumatic brain injury (TBI) is the main cause of
death in those under 45 years; at least this fact is still true in
On the other hand, the prognosis of TBI is improving.
The mortality after severe head injuries has been cut in half
compared to the 1980s. The advances in the outcome of TBI
are the result of improving interactions between the rescue
system, traumatologists, neurosurgeons and anesthesiolo-
gists, intensive care units, and rehabilitation medicine.
However, beside all improvements in the management of
head injuries, there are still unsolved problems, in particular
in the interaction of TBI with polytrauma. Overall, 78% of
all patients with TBI suﬀer additional injuries [1, 2]. Focus-
ing on emergency room patients show that 37% of all pol-
ytrauma patients suﬀer a TBI . TBI and thoracic injuries
are the most common lesions in polytrauma.
Traumatic brain injury in the multiply injured patient:
does it mean mainly a severe head injury with some
additional peripheral injuries or is it a polytraumatized
patient with a head injury among the other injuries? Or
is polytrauma with brain injuries a speciﬁc and separate
The reciprocal interaction of the injuries is supporting
this point of view. For example, the quite common rupture
of the infundibulum of the hypophysis caused by a fracture
of the base of the skull will aﬀect the whole body, e.g., by
hypothyreosis or diabetes insipidus with uncontrolled vol-
Paresis caused by brain damage inﬂuences the postopera-
tive results of fracture treatment. On the other hand, reduced
mobility due to multiple fractures of the limbs inﬂuences the
ability to relearn walking.
Injuries of the body have a great inﬂuence on the brain
injury, e.g., acute respiratory distress syndrome will cause
reduced brain oxygenation, and increased intra-abdominal
and thoracic pressure might result in a sustained increase
in intracranial pressure due to the reduced venous drainage
out of the brain.
Two other facts may underline the opinion that pol-
ytrauma with TBI is a speciﬁc syndrome: there is a strict
correlation between the severity grading in TBI and the
severity of the polytrauma ; and the mean cause of death
in the multiply injured patient is still the brain trauma.
The literature favors a small volume resuscitation in
multiply injured patients without TBI [5, 6]. But in patients
with an additional TBI, normotension is the aim. Is this a
To underline the importance of TBI in emergency sur-
gery, this issue of the European Journal of Trauma and
Emergency Surgery is dedicated to brain trauma and focuses
on recent topics.
Haltmeier et al.  contribute a new study to the long-
lasting controversy about prehospital intubation strategies
in the US vs. Europe in severe head injuries, demonstrating
a worse outcome and a higher mortality in the intubated
patients. This result is opposed to central European guide-
lines and the guidelines of the European Brain Injury Con-
sortium. In these guidelines, the prehospital intubation of
comatose patients (GCS < 9) is mandatory.
The underlying question is still unsolved: the group
with intubation has a lower Glasgow coma scale score in
the emergency room; does this mean that only the really
critically severe TBI patients are intubated in the prehospital
setting? In this case, the worse outcome of these patients
more closely reﬂects the poor incoming condition than the
diﬃculties of prehospital intubation.
Recent discussions about TBI not only deal with severe
head injury, but nowadays there is a focus shift to the vast
majority of TBI—the so-called mild TBI and concussion.
By deﬁnition the neurological symptoms of a mild TBI will
vanish within days, and a full recovery is expected.
* Eckhard Rickels
Department of Neurotraumatology, Allgemeines
Krankenhaus Celle, Celle, Germany