2. Management of Severe Traumatic Brain Injury

Management of Severe Traumatic Brain Injury

Date: 03/2026 | Supersedes: 11/2024 | Location: MH Katy

Definitions:

Severe TBI – Glasgow Coma Scale (GCS) of 3 to 8 without systemic sedation and after resuscitation
Moderate TBI – GCS of 9 to 12 without systemic sedation and after resuscitation
Mild TBI – GCS 13 to 14 without systemic sedation and after resuscitation

Intracranial Pressure Monitoring:

  • ICP monitoring is performed based upon admission GCS. Admission GCS is determined post-resuscitation and after paralytics and sedation wear off.
  • Indications for ICP monitoring:
    • GCS 3-8 with structural brain injury seen on initial imaging
  • Consider ICP monitoring in:
    • Patients with GCS >8 who have injuries at high risk for progression
    • Patients with GCS >8 when knowing the ICP may facilitate management of other issues (e.g. earlier surgery for orthopedic injuries; prone positioning for spine surgery)
    • Patients with evidence of progression on CT imaging or clinical deterioration
    • Patients who require urgent surgery for extracranial injuries or sedation to facilitate mechanical ventilation because of respiratory failure.

Tier 0: Principles of Care

  • q1 hour neurological checks in ICU
  • Elevate HOB ≥30°, unless contraindicated by spine fractures
  • Ensure adequate analgesia and sedation
  • Avoid hypothermia and hyperthermia. Consider cooling measures (acetaminophen, cooling blanket) for temperatures >38.0°C.
  • Provide early post traumatic seizure prophylaxis
  • Maintain CPP ≥60 mmHg
  • Maintain hemoglobin >7 g/dL
  • Avoid tight cervical collars and endotracheal tube ties. Maintain the head and neck in a neutral position (remove collar when possible according to established C-spine guidelines)
  • Place an arterial line for blood pressure measurement and frequent labs
  • Maintain SpO2 ≥94%
  • Review goals of care below

Goals of Care:

Neuro ICP <22 mmHg
CPP 60-70 mmHg
Seizure prophylaxis 7 days duration of anti-spileptic
Head of bed ≥30 degrees
CV SBP ≥110 mmHg
Pulm SpO2 ≥94%
PaO2 80-100 mmHg
PaCO2 35-45 mmHg
pH 7.35-7.45
Heme/Coag Hgb ≥7 g/dL
Platelets ≥75 x 103/mm3
QStat Clot Time <146
QStat Clot Stiffness >15.3
QStat Fibrinogen Contribution to Stiffness >1.6
QStat Platelet Contribution to Stiffness >13.3
QStat Clot Stability to Lysis ≥90%
DVT prophylaxis TED/SCDs; initiate VTE prophylaxis per protocol (hyperlink)
Glucose 100-180 mg/dL
Endo Serum Osmolality ≤320 mOsm
Renal Serum Na >135
Nutrition Early enteral feeding; full support by 7 days
GI Stress ulcer prophylaxis PPI

For Sustained (>10 minutes) ICP Elevations > 22 mmHg.

  • Always consider an expanding mass lesion with ICP elevations refractory to therapy and obtain a CT Head.
  • Tier 1 Therapies
    • Maintain CPP 60-70
    • Increase sedation and analgesia to lower ICP
    • Maintain PaCO2 at low end of normal (35-38 mmHg)
    • Initiate hyperosmolar therapy: goal serum Na 140-155, goal serum osmolality 280-320).
      • Hypertonic saline:
        • Bolus therapy: 250cc of 3% NaCl infused over 20 minutes up to q4h prn (OR)
        • Bolus therapy: 30cc of 23.4% NaCl infused over 30 minutes up to q4h prn
        • Hold hypertonic saline if serum Na >155 and/or serum osmolality >320
      • CSF drainage if EVD is already placed
      • Consider placement of EVD to drain CSF
      • Consider EEG monitoring to rule out seizures
  • Tier 2 Therapies
    • Mild hypocapnia (range 32-35 mmHg)
    • Paralysis: rocuronium 1 mg/kg IV x once (or vecuronium 10 mg IV) and evaluate for response. If paralysis improves ICP, start continuous infusion
    • Perform MAP challenge – increase MAP by 10 mmHg using vasopressors for not more than 20 minutes. Monitor MAP, CPP, and ICP before and after the challenge. If auto regulation is intact and the ICP drops, raised CPP with fluid or vasopressors.
  • Tier 3 Therapies
    • Barbiturate coma with continuous EEG monitoring.
      • Load: 10-mg/kg pentobarbital IV over 30 minutes, then 5 mg/kg q1h x 3 doses
      • Maintenance: 1 mg/kg/hr
    • Secondary decompressive craniectomy, in consultation with Neurosurgery.
    • Mild hypothermia; goal 35-36°C using active cooling measures

 For sustained (> 10 min) Cerebral Perfusion Pressure <60 mmHg

  1. Ensure euvolemia:
    • Urine output > 0.5cc/kg/hour
    • SVV < 15
  2. Ensure ICP <22 mmHg
    • See ICP management section above
  3. Begin pressors if euvolemic and CPP remains <60:
    • Norepinephrine preferred.
    • Alternative agents include phenylephrine or vasopressin.

For Acute Clinical Deterioration – acute mental status change, evidence of cerebral herniation, new focal neurologic symptoms, progressive (2 bolus of hyperosmolar therapy in 24 hours) and refractory ICP elevation (ICP > 22 mmHg despite initial intervention):

  1. ABC’s: Verify patent airway, oxygenation, and ventilation.
  2. Re-dose osmotic agent
  3. Call Neurosurgery immediately and
  4. Obtain EMERGENCY CT Head

References:

  1. Guidelines for the Management of Severe TBI, 4th Edition
  2. SIBICC Severe TBI Algorithm (https://braintrauma.org/coma/guidelines/sibicc-severe-tbi-algorithm-for-patients-with-icp-monitoring (external link))