Management of Severe Traumatic Brain Injury

Original Date: 08/2005 | Supersedes: 05/2017 | Last Review Date: 12/2020
Purpose: To provide recommendations for the treatment and management of patients with traumatic brain injury.

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

Intracranial Pressure Monitoring:

  • ICP monitoring is performed based upon admission GCS. Admission GCS is determined post-resuscitation and after paralytics and sedation wear off.
  • Admission GCS and ICP monitor placement should occur within 6 hours of arrival to the ED.
  • Indications for ICP monitoring:
    • GCS 3-81, or
    • Any patient with CT findings consistent with intracranial hemorrhage or indicative of elevated ICP2, or
    • Any patient with an abnormal CT Head in whom a neurologic exam will be unable to be obtained for any extended period (e.g., prolonged general anesthesia or neuromuscular blockade)

*If a patient has an above listed indication for ICP monitoring but does not receive an ICP monitor, please contact the Neurosurgery service. Know if an appropriate contraindication exists.*

Principles of Care:

  • Elevate HOB ≥30 degrees, unless contraindicated by spine fractures
  • Ensure adequate pain control with intermittent or continuous infusion of morphine or fentanyl.
  • Propofol should be the first choice for sedation in the acute phase (0-48 hours). Transition to other sedative after 48-72 hours as tolerated.
  • Maintain euvolemia.
  • Maintain serum sodium > 140 mEq/L.
  • Avoid hypothermia and hyperthermia. Consider cooling measures (acetaminophen, cooling blanket) for temperatures >100°F.
  • 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)
  • If patient requires invasive monitoring of intracranial pressure:
    • Obtain q6 BMP and serum osmolality; consider adding ABG, CBC, and/or TEG for the first 24h, longer if clinically indicated
    • Place a subclavian or internal jugular CVC to monitor CVP
    • Place an arterial line for blood pressure measurement and frequent labs
    • Refers to Goals of Care for parameter targets.

Goals of Care:

<td≥7 g/dL

Neuro ICP <22 mmHg3
CPP >60 mmHg4, 5
Seizure prophylaxis 7 days duration of anti-epileptic6
(https://med.uth.edu/surgery/post-traumatic-seizure-prophylaxis-in-patients-with-traumatic-brain-injury-clinical-practice-guideline/)
Head of bed >30 degrees
CV SBP >90 mmHg7, 8, 9
CVP >5 mmHg
Pulm SpO2 >93%9
PaO2 > 60 mmHg
PaCO2 35-42 mmHg10
Coag
(in the first 24h)		 TEG r-time <8 min
rTEG ACT <128 sec
TEG/rTEG k-time <2.5 min
TEG/rTEG alpha angle >60 degrees
TEG/rTEG mA >55 mm
TEG/rTEG lysis <3 %
Hgb
DVT prophylaxis TED/SCDs; initiate chemoprophylaxis 24 hours after stable CT Head
Endo Glucose 80-180 mg/dL
Renal Serum Osmolality 280-320
Serum Na 145-165
GI Nutrition Early enteral feeding; full support by 7 days
Stress ulcer prophylaxis Famotidine

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

  • Always consider an expanding mass lesion for ICP elevations refractory to therapy and obtain a CT Head.
  • First Tier Therapies (low-risk, non-invasive therapies shown to decrease ICP):
    • Ensure head of bed > 30 degrees
    • Maintain normothermia (36.5-37.9 C [97.7-100.3 F])
    • Avoid external compression of neck from cervical collar
    • Ensure that the neck is in a midline, neutral position
    • Provide adequate sedation and analgesia
  • Second Tier Therapies (interventions that carry some risk; shown to decrease ICP and improve mortality and neurologic outcomes compared to placebo)12
    • Initiate hyperosmolar therapy (goal serum Na 145-165 mEq/L, goal serum osmolality 280-320).
      • Hypertonic saline:
        • Maintenance fluid: 3% NaCl as a continuous infusion at a rate of 30 mL/h
        • 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 >165 and/or serum osmolality >320
      • Mannitol:
        • Bolus therapy: 0.25-1 g/kg over 20 minutes followed by 0.25 g/kg q6 hours.3
        • Hold mannitol if serum osmolality is >320
  • Third Tier Therapies (high risk interventions; may decrease ICP but no proven benefit for mortality or neurologic outcomes; may cause adverse events that outweigh the potential benefit):13,14,15
    • Paralysis: rocuronium 1 mg/kg IV x once (or vecuronium 10 mg IV) and evaluate for response. If paralysis improves ICP, start continuous infusion.
    • Hypothermia (goal 34-35°C)13
    • Barbiturate coma with continuous EEG monitoring.3,14
      • Load: 10-mg/kg pentobarbital IV over 30 minutes, then 5-mg/kg q1h x 3 doses
      • Maintenance: 1 mg/kg/h
    • Craniectomy, in consultation with Neurosurgery.15

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

  1. Ensure euvolemia:
    • Urine output > 0.5cc/kg/hour
    • CVP > 5mmHg
    • SVV < 15
    • Place pulmonary artery catheter if volume status is unclear utilizing noninvasive measurements
  2. Ensure ICP <22 mmHg
    • See ICP management section above
  3. Begin vasopressors if euvolemic and CPP remains <60:
    • Norepinephrine gtt if HR<100
    • Phenylephrine gtt if HR>100
    • Add vasopressin with escalating doses of pressors (0.04 U/min, do not titrate)

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 EMERGENT CT Head

References:

  1. Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. PMID: 27654000.
  2. Miller MT, Pasquale M, Kurek S, White J, Martin P, Bannon K, Wasser T, Li M. Initial Head Computed Tomographic Scan Characteristics Have a Linear Relationship with Initial Intracranial Pressure after Trauma. J Trauma. May 2004;56(5):967-72.
  3. Eisenberg HM, Frankowski RF, Contant C, Marshall LM, Walker MD. High-Dose Barbiturate Control of Elevated Intracranial Pressure in Patients with Severe Head Injury. J Neurosurg. Jul 1988;69(1):15-23.
  4. Robertson CS, Valadka AB, Hannay HJ, Contant CF, Gopinath SP, Cormino M, Uzura M, Grossman RG. Prevention of Secondary Ischemic Insults after Severe Head Injury. Crit Care Med. Oct 1999;27(10):2086-95.
  5. Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial Hypertension and Cerebral Perfusion Pressure: Influence on Neurological Deterioration and Outcome in Severe Head Injury. J Neurosurg. Jan 2000;92(1):1-6.
  6. Temkin NR, Dikmen SS, Anderson GD, Wilensky AJ, Holmes MD, Cohen W, Newell DW, Nelson P, Awan A, Winn HR. Valproate Therapy for Prevention of Posttraumatic Seizures: a Randomized Control. J Neurosurg. Oct 1999;91(4):593-600.
  7. Chestnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. The Role of Secondary Brain Injury in Determining Outcome from Severe Head Injury. J Trauma. Feb 1993;34(2):216-22.
  8. Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF, Eisenberg HM, Foulkes MA, Marshall LF, Jane JA. Impact of ICP Instability and Hypotension on Outcome in Patients with Severe Head Trauma. J Neurosurg. Nov 1991;75(1S):S59-66.
  9. Jones PA, Andrews PJ, Midgley SI, Piper IR, Tocher JL, Housley AM, Corrie JA, Slattery J, Dearden NM. Measuring the Burden of Secondary Insults in Head-Injured Patients During Intensive Care. J Neurosurg Anesthesiol. Jan 1994;6(1):4-14.
  10. Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF. Adverse Effects of Prolonged Hyperventilation in Patients with Severe Head Injury: a Randomized Clinical Trial. J Neurosurg. Nov 1991;75(5):731-9.
  11. Chiang YH, Chao DP, Chu SF, Lin HW, Huang SY, Yeh YS, Lui TN, Binns CW, Chiu WT. Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage: a Multi-Center Cohort Study. J Neurotrauma. Jan 2012;29(1):75-80.
  12. Chen H, Song Z, Dennis JA. Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 30;12(12):CD010904. doi: 10.1002/14651858.CD010904.pub2. Update in: Cochrane Database Syst Rev. 2020 Jan 17;1:CD010904. PMID: 31886900; PMCID: PMC6953360.
  13. Lewis SR, Evans DJ, Butler AR, Schofield-Robinson OJ, Alderson P. Hypothermia for traumatic brain injury. Cochrane Database Syst Rev. 2017 Sep 21;9(9):CD001048. doi: 10.1002/14651858.CD001048.pub5. PMID: 28933514; PMCID: PMC6483736.
  14. Roberts I, Sydenham E. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev. 2012 Dec 12;12(12):CD000033. doi: 10.1002/14651858.CD000033.pub2. PMID: 23235573; PMCID: PMC7061245.
  15. Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 31;12(12):CD003983. doi: 10.1002/14651858.CD003983.pub3. PMID: 31887790; PMCID: PMC6953357.