Acute Management of Severe TBI

Patients with severe traumatic brain injury (TBI) are most optimally managed in a specialized neurotrauma center with neurosurgical and neurocritical care support and the use of guidelines-based standardized protocols.

Prevention of hypoxia (PaO2 <60 mmHg) and hypotension (systolic BP <90 mmHg) are priorities in the management of patients with severe TBI beginning with their prehospital care.

Emergency department evaluation should include frequent clinical neurologic assessments and a computed tomography (CT) scan of the head.

When impending herniation due to elevated intracranial pressure (ICP) is suspected in a patient with severe TBI, we recommend treatment with head of bed elevation and intravenous mannitol pending the results of the CT and measurement of intracranial pressure (ICP) (Grade 1B). (See 'Emergency department' above.)

Surgical evacuation of epidural, subdural, and intracerebral hematomas are performed based upon blood volume and associated mass effect, in conjunction with the patient's neurologic status.

We recommend ventriculostomy placement with ICP monitoring in patients with severe TBI and an abnormal CT scan showing evidence of mass effect from lesions such as hematomas, contusions or swelling.

We recommend treatment of elevated ICP to target pressures below 20 mmHg (Grade 1B). Appropriate first measures include removal of cerebrospinal fluid through the ventriculostomy, head of bed elevation, followed by osmotic therapy with mannitol. For patients with elevated ICP refractory to initial therapy, treatment options include hyperventilation, barbiturate coma, induced hypothermia, and decompressive craniectomy. Hyperventilation should be avoided in the first 24 to 48 hours and should not exceed PaCO2 <30 mmHg.

We recommend using normal saline to maintain euvolemia (Grade 1B).
Cerebral perfusion pressure (CPP) (the difference between mean arterial pressure and ICP) should be continuously assessed. The suggested CPP target is 60 mmHg, avoiding CPP >70 mmHg and <50 mmHg, which should be achieved by optimizing ICP first and then MAP (with volume expansion, pressors) second.

We recommend short-term (one week) use of antiepileptic drugs (phenytoin, valproate) for the prevention of early seizures (Grade 1B).

We suggest that fever and hyperglycemia be avoided for their potential to exacerbate secondary neurologic injury. Coagulopathy should be corrected to maintain an INR < 1.4 and a platelet count > 75,000/mm3.

We recommend thromboprophylaxis for the prevention of venous thromboembolism (Grade 1A). The use and timing of antithrombotic agents is individualized based upon an assessment of the competing risks of venous thrombosis and intracranial hemorrhage expansion. Patients not receiving antithrombotic therapy should wear pneumatic compression stockings.

We recommend NOT using glucocorticoids for the management of patients with severe TBI (Grade 1A).

The use of sedative medications should be individualized. Options include barbiturates, propofol, fentanyl, benzodiazepines, and morphine. These can be used individually, in combination, and/or with neuromuscular blockade. Blood pressure, ICP, and CPP should be monitored as these are somewhat unpredictably affected by these medications.

This post was excerpted from uptodate.com by Angela Chiang, MS4