Traumatic Brain Injury (TBI)

Epidemiology

  • Traumatic Brain Injury (TBI) is the Leading Cause of Death for Patients Age 1-45 y/o in North America [MEDLINE]
    • Many Survivors Have Significant Disability

Physiology

Primary Brain Injury

  • General Comments: primary brain injury occurs at the time of trauma
  • Mechanisms of Primary Brain Injury
    • Diffuse Axonal Injury Due to Shearing: usually involves the hemispheric gray-white matter junction, corpus callosum, and/or midbrain
      • Usually present with coma without an increase in intracranial pressure
    • Focal Cerebral Contusion: common in basal frontal and temporal regions (due to susceptibility to direct impact on the basal skull surface during acceleration/deceleration injuries)
      • These are the most frequently observed lesions
      • Intraparenchymal hematoma may occur from coalescence of cerebral contusions or disruption of intraparenchymal blood vessels
    • Extra-Axial Hematoma
      • Epidural Hematoma (see Epidural Hematoma, [[Epidural Hematoma]]): due to tear in dural vessels (middle meningeal artery, etc)
        • Almost always associated with skull fracture
        • Tend to not be associated with underlying parenchymal brain injury
      • Intraventricular Hemorrhage: due to tearing of subependymal veins, extension from adjacent intraparenchymal hemorrhage, or extension from subarachnoid hemorrhage
      • Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]]): due to disruption of small pial vessels, extension from intraventricular hemorrhage, or extension from superficial parenchymal hemorrhage
        • Tend to occur in the sylvian fissures and interpeduncular cisterns
      • Subdural Hematoma (SDH) (see Subdural Hematoma, [[Subdural Hematoma]]): due to damage to bridging veins (which drain cerebral cortical surfaces to dural venous sinuses) or from extension from superficial cortical contusions
        • Tend to be associated with underlying parenchymal brain injury

Secondary Brain Injury

  • General Comments: secondary brain injury occurs subsequent to the initial trauma and continues for hours-days
  • Mechanisms of Secondary Brain Injury
    • Apoptosis
    • Electrolyte Imbalance
    • Inflammatory Response
    • Mitochondrial Dysfunction
    • Neurotransmitter-Mediated Excitotoxicity Resulting in Glutamate, Free-Radical Injury to Cell Membranes
    • Secondary Brain Ischemia Resulting from Vasospasm, Focal Microvascular Occlusion, and Vascular Injury

Other Aspects

  • Impaired Cerebral Autoregulation
    • Normally, Via Autoregulation, the Brain Maintains an Adequate Cerebral Blood Flow Across a Wide Range of Mean Arterial Blood Pressures (MAP) From 50-100 Meg Hg
    • In TBI, Cerebral Autoregulation is Impaired in Approximately 33% of TBI Cases: resulting in the brain demonstrating “pressure-passive” hemodynamics
      • Increased MAP (hypertension) may then result in increased cerebral blood flow and hypermedia, resulting in elevated intracranial pressure (ICP)
      • Decreased MAP (hypotension) may result in brain hypoperfusion and ischemia

Diagnosis

Head CT (see Head Computed Tomography, [[Head Computed Tomography]])

  • xxx

Brain MRI (see Brain Magnetic Resonance Imaging, [[Brain Magnetic Resonance Imaging]])

  • xxx

External Ventricular Drain (EVD) (see External Ventricular Drain, [[External Ventricular Drain]])

  • Indications for Monitoring in the Setting of Traumatic Brain Injury
    • Survivable Severe TBI with Associated Abnormalities on Head CT at Time of Admission
    • TBI in Patient Age >40 y/o with Hypotension or Abnormal Flexion/Extension in Response to Pain with Normal Head CT at Time of Admission
  • Contraindications
    • Coagulopathy (see Coagulopathy, [[Coagulopathy]]): relative contraindication
    • Thrombocytopenia with Platelets <100k (see Thrombocytopenia, [[Thrombocytopenia]]): relative contraindication
  • Adverse Effects/Complications
    • Intracerebral Hemorrhage: rate of hemorrhage with ventricular catheter is 1-7%
      • Rate of Hemorrhage for Intraparenchymal Monitor is Less Than That of Ventricular Catheter
      • Hemorrhages Rarely Require Surgical Evacuation
    • Infection/Ventriculitis (see Central Nervous System Device Infection, [[Central Nervous System Device Infection]])
      • Culture of Tip of External Ventricular Drains May Demonstrate Bacterial Colonization: however, the rate of invasive infection is lower
      • Risk of Infection is Higher with Ventricular Catheter (1-27%) Than with Parenchymal Monitor
      • Risk Factors for Infection
        • Leakage Around the Ventriculostomy Site
        • Longer Duration of Catheter Placement
        • Presence of Open Skull Fracture with Leakage of Cerebrospinal Fluid

Glasgow Coma Scale (GCS)

  • Eye Opening
    • Spontaneous: 4
    • Response to Verbal Command: 3
    • Response to Pain: 2
    • No Eye Opening: 1
  • Best Verbal Reponse
    • Oriented: 5
    • Confused: 4
    • Inappropriate Words: 3
    • Incomprehensible Sounds: 2
    • No Verbal Response: 1
  • Best Motor Response
    • Obeys Commands: 6
    • Localizing Response to Pain: 5
    • Withdrawal Response to Pain: 4
    • Flexion to Pain: 3
    • Extension to Pain: 2
    • No Motor Response: 1
  • Total
    • Range: 3-15 (3 is the worst and 15 is the best)
    • Score 13+: mild brain injury
    • Score 9-12: moderate brain injury
    • Score 8 or Less: severe brain injury

Clinical Manifestations

Hematologic Manifestations

  • Coagulopathy (see Coagulopathy, [[Coagulopathy]])
    • Epidemiology: approximately 33% of TBI patients develop coagulopathy -> this is associated with increased risk of hemorrhage, poor neurologic outcome, and increased mortality rate
    • Physiology: systemic release of tissue factor and brain phospholipid -> Intravascular coagulation and consumptive coagulopathy

Neurologic Manifestations

Anxiety/Depression (see Anxiety, [[Anxiety]] and Depression, [[Depression]])

  • Epidemiology: high rates are noted following TBI

Chronic Pain

  • Epidemiology: common following TBI
    • May Further Exacerbate Sleep Disturbances

Coma (see Obtundation-Coma, [[Obtundation-Coma]])

  • Epidemiology: xxx

Increased Intracranial Pressure (see Increased Intracranial Pressure, [[Increased Intracranial Pressure]])

  • xxxx

Post-Traumatic Stress Disorder (PTSD) (see Post-Traumatic Stress Disorder, [[Post-Traumatic Stress Disorder]])

  • Epidemiology: common (especially in military populations) following TBI

Seizures (see Seizures, [[Seizures]])

  • Epidemiology
    • Incidence of Seizures Within the First 1-2 Weeks: 6-10% (although may be as high as 30%)
    • Incidence of Non-Convulsive Seizures: 15-25% in patients with TBI and coma

Sleep-Wake Disturbances

  • Epidemiology: prevalent and persistent following TBI
  • Clinical: may occur acutely or chronically following TBI of any severity
    • Difficulty Maintaining Sleep
    • Early Morning Awakenings
    • Excessive Daytime Somnolence (see Excessive Daytime Somnolence, [[Excessive Daytime Somnolence]])
    • Increased Need for Sleep
    • Insomnia (se Insomnia, [[Insomnia]])
    • Nightmares (see Nightmares, [[Nightmares]])
    • Sleep Fragmentation

Pulmonary Manifestations

Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]])

  • Epidemiology

Increased Risk for Obstructive Sleep Apnea (OSA)/Central Sleep Apnea (CSA)

  • Epidemiology: prevalence of obstructive sleep apnea was 23% following TBI [MEDLINE]

Other Manifestations

  • xxxx

Treatment

General Measures

  • Correction of Electrolyte Imbalances: when present
  • Care in Specialized Trauma Center: associated with improved outcome
    • Study of the Impact of High-Volume Trauma Centers on Outcome After TBI (J Trauma Acute Care Surg, 2013) [MEDLINE]

Deep Venous Thrombosis (DVT) Prophylaxis (see Deep Venous Thrombosis, [[Deep Venous Thrombosis]])

  • Measures
    • Sequential Compression Devices (SCD’s)
    • Pharmacologic Prophylaxis
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Graduated Compression Stockings/Sequential Compression Device (SCD’s) are Recommended (Level III Recommendation): continue use until patient is ambulatory
    • Low Molecular Weight Heparin or Low Dose Unfractionated Heparin Should Be Used in Combination with Mechanical Prophyaxis (Level III Recommendation): however, there is an increased risk of expansion of intracranial hemorrhage
      • Insufficient Evidence to Determine the Preferred Agent, Dose, or Timing of Pharmacologic DVT Prophylaxis

Hemodynamic Management

  • Rationale: hypotension causes cerebral vasodilation
  • Hemodynamic Monitoring
    • Monitor Central Venous Pressure (CVP): to maintain adequate fluid status
  • Clinical Efficacy
    • SAFE Study: Comparing Crystalloid (Normal Saline) vs Colloid (4% Albumin) in Heterogenous Population of ICU Patients (2004) [MEDLINE]: colloid (albumin) use in the subgroup of patients with TBI resulted in a higher mortality rate
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Hypotension <90 mm Hg Should Be Avoided (Level II Recommendation)

Hemostatic Therapy

  • Recommendations
    • Management of Non-Coagulopathic Patients: hemostatic therapy is not indicated
    • Management of Elevated INR (Unrelated to Coumadin): maintain INR <1.4 with FFP, prothrombin complex concentrate, etc
      • Role of Recombinant Factor VIIa (NovoSeven RT) (see Factor VIIa, [[Factor VIIa]])
        • FVIIa Traumatic ICH Study Group Prospective Trial in TBI (Neurosurgery, 2008) [MEDLINE]: recombinant factor VIIa decreased hematoma progression, but did not decrease the mortality rate (but there was a trend toward increased rate of DVT’s at day 3)
    • Management of Coumadin Anticoagulation (If Present): maintain INR <1.4
    • Management of Platelet Dysfunction (Drug-Induced, etc)
      • Systematic Review of Platelet Transfusion in TBI in Patients on Pre-Injury Antiplatelet Therapy (J Trauma Acute Care Surg, 2012) [MEDLINE]: platelet transfusion in this setting is of unclear benefit (due to poor quality data)
    • Management of Thrombocytopenia (If Present): maintain platelet count >75k

Infection Prophylaxis

  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Peri-Procedural Antibiotics are Recommended for Intubation to Decrease the Risk of Pneumonia (Level II Recommendation): however, these do not decrease length of stay or mortality rate
    • Early Tracheostomy Should Be Performed to Decrease Ventilator Days (see Tracheostomy, [[Tracheostomy]]): however, it does not decrease mortality rate or rate of pneumonia
    • Routine Ventricular Catheter Exchange to Prevent Infection is Not Recommended (Level III Recommendation)
    • Prophylactic Antibiotics to Prevent Ventricular Catheter Infection are Not Recommended (Level III Recommendation)
    • Early Extubation in Qualified Patients Can Be Done Without an Increased Risk of Pneumonia (Level III Recommendation)

Management of Increased Intracranial Pressure (see Increased Intracranial Pressure, [[Increased Intracranial Pressure]])

Analgesia

  • Agents
    • Fentanyl (Sublimaze) (see Fentanyl, [[Fentanyl]])
    • Morphine (see Morphine, [[Morphine]])
    • Sufentanil (Sufenta) (see Sufentanil, [[Sufentanil]])

Central Venous Pressure (CVP) Monitoring (see Hemodynamics, [[Hemodynamics]])

  • Recommendations
    • Avoid Hypervolemia

Corticosteroids (see Corticosteroids, [[Corticosteroids]])

  • Clinical Efficacy
    • MRC CRASH Trial (Lancet, 2004) [MEDLINE]
      • Corticosteroids Increased the Mortality Rate within the First 2 wks Following TBI
    • MRC CRASH Trial Follow-Up Study (Lancet, 2005) [MEDLINE]
      • Corticosteroids Increased the Mortality Rate at 6 mo in TBI
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Corticosteroids are Not Recommended to Decrease Intracranial Pressure: high dose methylprednisolone is associated with increased mortality in moderate-severe TBI

Decompressive Craniectomy (see Decompressive Craniectomy, [[Decompressive Craniectomy]])

  • Procedure: removal of part of skull may be done solely to decrease the intracranial pressure or as part of an evacuation procedure
  • Clinical Efficacy: clinical benefit in TBI is unclear, further study is required
    • DECRA Trial (NEJM, 2011) [MEDLINE]
      • Bifrontotemporoparietal Decompressive Craniectomy in Adults with TBI and Refractory Increased ICP Decreased ICP and Length of ICU Stay, But was Associated with No Impact on Mortality and a Higher Number of Unfavorable Outcomes
    • Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) Study: results pending
  • Complications
    • Infection

Elevation of Head of to Bed to 30 Degrees

  • Standard Therapy

Hypertonic Saline (see Hypertonic Saline, [[Hypertonic Saline]])

  • Pharmacology: probably induces osmotic mobilization of water across the intact blood-brain barrier, decreasing cerebral water content
  • Adverse Effects
    • Fluid Overload (Due to Sodium Load)
    • Hypernatremia (see Hypernatremia, [[Hypernatremia]])
  • Clinical Efficacy
    • Comparison of Mannitol with 23.4% Hypertonic Saline in Decreasing Intracranial Pressure in TBI (Neurosurgery, 2005) [MEDLINE]
      • No Difference Between Mannitol and Hypertonic Saline (23.4%) in Decreasing in ICP in TBI: however, duration of hypertonic saline effect (96 min) was longer than that of mannitol (59 min)
    • Systematic Review and Meta-Analysis of Hypertonic Saline (Crit Care Med, 2013) [MEDLINE]
      • Hypertonic Saline (23.4%) Decreased Intracranial Pressure by 50% within 60 min in TBI
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Insufficient Evidence to Make Recommendation for Use of Hypertonic Saline

Hyperventilation

  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Prophylactic Hyperventilation (pCO2 <25 mm Hg) is Not Recommended (Level II Recommendation)
    • Hyperventilation is Recommended as a Temporizing Measure to Decrease an Elevated Intracranial Pressure (Level III Recommendation)
      • However, Hyperventilation Should be Avoided During the First 24 hrs After Injury: during this period, cerebral blood flow is often critically decreased
      • If Hyperventilation is Used, Jugular Venous Oxygen Saturation (SjO2) or Brain Tissue Oxygenation are Recommended to Monitor Therapy

Intracranial Pressure (ICP) Monitoring (see Increased Intracranial Pressure, [[Increased Intracranial Pressure]])

  • Rationale
    • Cerebral Perfusion Pressure is a Surrogate for Cerebral Blood Flow
    • Cerebral Perfusion Pressure (CPP) = MAP – ICP
    • Episodes of Hypotension, Increased ICP, and Low CPP are Associated with Secondary Brain Injury and Worse Outcome (J Neurosurg, 2002) [MEDLINE]
    • Allows Drainage of Cerebrospinal Fluid from Ventricle: when using an external ventricular drain
  • Indications (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • All Salvageable Patients with Severe TBI, GCS 3-8 After Resuscitation, and an Abnormal CT Scan (Hematoma, Contusion, Edema, Herniation, Compressed Basal Cisterns) (Level II Recommendation)
    • Severe TBI with Normal CT Scan with Two or More Criteria at Admission: Age >40 y/o, Unilateral or Bilateral Motor Posturing, SBP <90 mm Hg (Level III Recommendation)
  • Contraindications
    • Coagulopathy Which Cannot Be Corrected (see Coagulopathy, [[Coagulopathy]])
    • Infection Preventing Insertion
  • Device
  • Complications
    • Intracerebral Hemorrhage: rate of hemorrhage with ventricular catheter is 1-7%
      • Rate of Hemorrhage for Intraparenchymal Monitor is Less Than That of Ventricular Catheter
      • Hemorrhages Rarely Require Surgical Evacuation
    • Infection/Ventriculitis (see Ventriculitis, [[Ventriculitis]])
      • Culture of Tip of External Ventricular Drains May Demonstrate Bacterial Colonization: however, the rate of invasive infection is lower
      • Risk of Infection is Higher with Ventricular Catheter (1-27%) Than with Parenchymal Monitor
      • Risk Factors for Infection
        • Leakage Around the Ventriculostomy Site
        • Longer Duration of Catheter Placement
        • Presence of Open Skull Fracture with Leakage of Cerebrospinal Fluid
  • Clinical Efficacy
    • Trial of Intracranial Pressure Monitoring in TBI (NEJM, 2012) [MEDLINE]
      • Maintaining ICP <20 mm Hg Did Not Improve Outcome (Based on Functional and Cognitive Status), 6-Month Mortality Rate, or Median Length of ICU Stay, as Compared to Clinical Exam/Imaging-Based Management
  • Recommendations for Intracranial Pressure Thresholds (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Treatment Should Be Initiated for ICP >20 mm Hg (Level II Recommendation)
    • Combination of ICP + Clinical Findings + Brain Findings Should Be Used to Determine the Need for Treatment of ICP (Level III Recommendation)
  • Recommendations for Cerebral Perfusion Pressure Thresholds (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]: target CPP 50-70 mm Hg (patients with intact cerebral autoregulation will tolerate higher CPP values)
    • Maintenance of Cerebral Perfusion Pressure >70 mm Hg with Fluids/Pressors Should Be Avoided Due to Risk of ARDS (Level II Recommendation): excessive hypervolemia should be avoided
    • Cerebral Perfusion Pressure <50 mm Hg Should Be Avoided (Level III Recommendation)

Mannitol (see Mannitol, [[Mannitol]])

  • Indications
  • Pharmacology: osmotic diuretic
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Mannitol (Dose: 0.25-1.00 g/kg) is Effective to Control Increased Intracranial Pressure (Level II Recommendation)
      • Hypotension (SBP <90 mm Hg) Should Be Avoided
    • Restrict Mannitol Use Prior to Intracranial Pressure Monitoring to Patients with Transtentorial Herniation or Progressive Neurologic Deterioration Not Attributable to an Extracranial Etiology (Level III Recommendation)

Optimization of Cerebral Venous Drainage

  • Procedure
    • Loosen Neck Braces (If Too Tight)
    • Maintain Neck in Neutral Position

Sedation (see Sedation, [[Sedation]])

  • Agents
    • Barbiturates (see Barbiturates, [[Barbiturates]])
      • Pharmacology: decrease cerebral metabolism and cerebral blood flow (decreasing intracranial pressure)
      • Pentobarbital (see Pentobarbital, [[Pentobarbital]])
        • Load: 10 mg/kg over 30 min, 5 mg/kg q1hr x 3 doses (J Neurosurg, 1988) [MEDLINE]
        • Maintenance: 1 mg/kg/hr (J Neurosurg, 1988) [MEDLINE]
    • Dexmedetomidine (Precedex) (see Dexmedetomidine, [[Dexmedetomidine]])
      • Properties
        • Analgesic Effect
        • Anxiolytic Effect
        • Decreases Intracranial Pressure
        • Sedative Effect
        • Sympatholytic Effect
        • No Effect on Seizure Threshold
        • No Significant Respiratory Depression
    • Midazolam (Versed) (see Midazolam, [[Midazolam]])
    • Propofol (Diprivan) (see Propofol, [[Propofol]])
      • Properties
        • Amnestic Effect (see Amnesia, [[Amnesia]])
        • Anti-Emetic Effect
        • Anxiolytic Effect
        • Decreases Intracranial Pressure (see Increased Intracranial Pressure, [[Increased Intracranial Pressure]])
        • Increases Seizure Threshold
        • Sedative Effect
        • No Analgesic Effect
        • Large Lipid Load: requiring adjustment of enteral/parenteral nutritional support
  • Clinical Efficacy
    • Systematic Review of Sedatives in TBI (Crit Care MED, 2011) [MEDLINE]
      • No Evidence that Any Sedative is Superior to Another in TBI in Terms of Patient-Centered Outcomes, Intracranial Pressure, or Cerebral Perfusion Pressure
      • High Bolus Doses of Opiates Have Potentially Deleterious Effects on Intracranial Pressure and Cerebral Perfusion Pressure
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Propofol is Recommended for Increased Intracranial Pressure: however, propofol has not been shown to improve mortality or 6-mo outcome (in addition, high dose propofol can produce significant morbidity)
    • Barbiturates are Recommended for Increased Intracranial Pressure Refractory to Other Medical/Surgical Therapies

Therapeutic Hypothermia (see Therapeutic Hypothermia, [[Therapeutic Hypothermia]])

  • Rationale: therapeutic hypothermia lowers intracranial pressure
  • See Below Under “Management of Body Temperature”

Treatment of Fever (see Fever, [[Fever]])

  • Rationale: fever causes cerebral vasodilation
  • See Below Under “Management of Body Temperature”

Treatment of Hyponatremia (see Hyponatremia, [[Hyponatremia]])

  • Rationale: hyponatremia causes cerebral edema
  • Standard Therapy

Management of Seizures (see Seizures, [[Seizures]])

  • Rationale: seizures cause cerebral vasodilation
  • Agents
    • Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]]): increase seizure threshold
      • Lorazepam (Ativan) (see Lorazepam, [[Lorazepam]])
    • Propofol (Diprivan) (see Propofol, [[Propofol]]): increases seizure threshold
  • Clinical Efficacy
    • Systematic Review of Anti-Epileptic Drugs for Seizures Following TBI (Cochrane Database Syst Rev, 2001) [MEDLINE]
      • Prophylactic Anti-Epileptics are Effective in Decreasing Early Seizures
      • Prophylactic Anti-Epileptics Do Not Decrease the Occurrence of Late Seizures or Impact Neurologic Disability or Mortality Rate
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Anticonvulsants are Recommended to Decrease the Incidence of Early Post-Traumatic Seizures (Within 7 Days of Injury): however, post-traumatic seizures are not associated with worse outcomes
    • Prophylactic Phenytoin/Valproic Acid is Not Recommended to Prevent Late Post-Traumatic Seizures (Level II Recommendation)

Management of Serum Glucose

  • Clinical Efficacy
    • Study of Hyperglycemia in Traumatic Brain Injury (J Trauma, 2005) [MEDLINE]: early hyperglycemia is associated with poor outcome in severe TBI
  • Recommendations
    • Maintain Normoglycemia

Management of Body Temperature

Treatment of Fever (see Fever, [[Fever]])

  • Clinical Efficacy
    • Study of Predictors of Mortality in TBI (J Neurosurgery, 2002) [MEDLINE]: fever predicts poor outcome in TBI
  • Recommendations
    • Maintain Normothermia
  • Techniques
    • Anti-Pyretics
    • Endovascular Temperature Management Catheters
    • Surface Cooling Blankets

Therapeutic Hypothermia (see Therapeutic Hypothermia, [[Therapeutic Hypothermia]])

  • Rationale: therapeutic hypothermia lowers intracranial pressure
  • Clinical Efficacy
    • Cochrane Database Systematic Review of Therapeutic Hypothermia in Traumatic Brain Injury (Cochrane Database Syst Rev, 2009) [MEDLINE]: therapeutic hypothermia may be effective in reducing death and unfavourable outcomes for traumatic head injured patients, but significant benefit was found only in the low quality trials -> therapeutic hypothermia is not recommended in traumatic brain injury
    • Systematic Review of Therapeutic Hypothermia in Traumatic Brain Injury (CJEM, 2010) [MEDLINE]: prophylactic mild-to-moderate therapeutic hypothermia (32-34 degrees C) in traumatic brain injury (Glasgow coma scale score < or = 8) decreased mortality and improved rates of good neurologic recovery
      • Maximal benefit occurred with cooling continued for at least 72 hours and/or until stable normalization of intracranial pressure for at least 24 hrs
    • National Acute Brain Injury Study: Hypothermia II Trial (Lancet, 2011) [MEDLINE]: therapeutic hypothermia to 33 or 35 degrees C (in patients enrolled within 2.5 hrs of injury) had no clinical benefit in terms of Glasgow outcome scale score at 6 mo
      • Greater benefit from therapeutic hypothermia was observed in patients undergoing surgical removal of hematomas, as compared with those with diffuse axonal/brain injury
    • Systematic Review of Therapeutic Hypothermia in Traumatic Brain Injury (Brain Injury, 2012) [MEDLINE]: therapeutic hypothermia decreased intracranial pressure
  • Adverse Effects
    • Rewarming Can Increase Intracranial Pressure
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Prophylactic Therapeutic Hypothermia is Not Associated with Decreased Mortality in Traumatic Brain Injury (When Compared to Normothermic Controls) (Level III Recommendation)
      • However, When Maintained for >48 hrs, Mortality May Be Decreased
    • Prophylactic Therapeutic Hypothermia is Associated with Significantly Higher GCS Scores (When Compared to Normothermic Controls)
  • Recommendations
    • Therapeutic Hypothermia Has Unclear Clinical Benefit in TBI: however, may be considered in patients with refractory elevations in intracranial pressure, despite other therapy

Nutrition

  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Patients Should Be Fed to Attain Full Caloric Replacement by Day 7 Post-Injury

Renal Management

  • Choice of Intermittent Hemodialysis vs Continuous Venovenous Hemodialysis (CVVHD)
    • If Hemodialysis is Required, CVVHD is Preferred Over Intermittent HD, Due to Rapid Solute Changes and Potential for Hypotension with Intermittent HD (Which May Exacerbate Cerebral Ischemia) (see Hemodialysis, [[Hemodialysis]])

Respiratory Management

  • Indications for Intubation/Mechanical Ventilation
    • Glasgow Coma Scale Score <8: early intubation is recommended, if prehospital expertise is available
    • Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
      • Type I Hypoxemic Respiratory Failure
      • Type II Ventilatory/Hypercapnic Hypoxemic Respiratory Failure
  • Strategies for Mechanical Ventilation (see xxxx, [[xxxx]])
    • Avoid Coughing (see Cough, [[Cough]]): generally achieved using sedation, clearance of airway obstruction, etc
    • Avoid Hypoxemia (see Hypoxemia, [[Hypoxemia]]): hypoxemia causes cerebral vasodilation
    • Avoid Hypercapnia (see Hypercapnia, [[Hypercapnia]]): hypercapnia causes cerebral vasodilation
    • Patient-Ventilator Dyssynchrony: dyssynchrony increases venous pressure
  • Recommendations (Guidelines for the Management of Severe Traumatic Brain Injury, 2007) [MEDLINE]
    • Avoid Hypotension <90 mm Hg (Level II Recommendation)
    • Avoid Hypoxemia (pO2 <60 mm Hg or SaO2 <90%) (Level III Recommendation)

Surgical Management

Epidural Hematoma (see Epidural Hematoma, [[Epidural Hematoma]])

  • xxx

Subdural Hematoma (see Subdural Hematoma, [[Subdural Hematoma]])

  • xxx

Intracerebral Hemorrhage (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]])

  • xxx

Penetrating Brain Injury

  • xxx

Depressed Skull Fracture

  • xxx

XXX

  • xxx

Prognosis

  • Prognostic Factors in TBI [MEDLINE]
    • Glasgow Coma Score
    • Age
    • Pupillary Response/Size
    • Hypoxia
    • Hyperthermia
    • Increased Intracranial Pressure
  • Outcome After 1 Year in TBI [MEDLINE]
    • Good Recovery: 31.56%
    • Moderate Disability: 14.07%
    • Severe Disability: 24.35%
    • Vegetative State: 0.59%
    • Death: 29.43%

References

General

  • Early indicators of prognosis in 846 cases of severe traumatic brain injury. J Neurotrauma 2002;19(7):869-874. doi: 10.1089/08977150260190456 [MEDLINE]
  • Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg. 2002;97(2):326 [MEDLINE]
  • Early management of severe traumatic brain injury. Lancet. 2012 Sep;380(9847):1088-98 [MEDLINE]

Treatment

General

  • Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1:S1-106 [MEDLINE]
  • Guidelines for the management of severe traumatic brain injury.  Editor’s commentary. J Neurotrauma 2007; 24 Suppl 1:2 p preceding S1 [MEDLINE]
  • Prevalence and consequences of sleep disorders in traumatic brain injury. J Clin Sleep Med. 2007 Jun;3(4):349-56 [MEDLINE]
  • Traumatic brain injury: intensive care management.  Br J Anaesth  2007;99:32–42 [MEDLINE]
  • Mortality reduction after implementing a clinical practice guidelines-based management protocol for severe traumatic brain injury. J Crit Care 2010; 25:190-195 [MEDLINE]
  • A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med  2012;367:2471–2481 [MEDLINE]
  • Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012; 20:12 [MEDLINE]
  • Early management of severe traumatic brain injury. Lancet. 2012 Sep;380(9847):1088-98 [MEDLINE]
  • High-volume trauma centers have better outcomes treating traumatic brain injury. J Trauma Acute Care Surg. 2013 Jan;74(1):143-7; discussion 147-8 [MEDLINE]

Sedation

  • High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg. 1988 Jul;69(1):15-23 [MEDLINE]
  • Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011;39:2743–2751 [MEDLINE]
  • Sedation in traumatic brain injury. Emerg Med Int. 2012; vol 2012; article ID 637171, pp 1–11 [MEDLINE]

Hemodynamic Management

  • SAFE Study. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247–2256 [MEDLINE]

Hemostatic Therapy

  • rFVIIa Traumatic ICH Study Group. Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery. 2008 Apr;62(4):776-86; discussion 786-8 [MEDLINE]
  • Utility of platelet transfusion in adult patients with traumatic intracranial hemorrhage and preinjury antiplatelet use: a systematic review. J Trauma Acute Care Surg. 2012 Jun;72(6):1658-63 [MEDLINE]

Corticosteroids

  • Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004;364(9442):1321 [MEDLINE]
  • Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365(9475):1957 [MEDLINE]

Management of Increased Intracranial Pressure

  • Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. J Trauma. 1998;44(1):50 [MEDLINE]
  • Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery. 2005;57(4):727 [MEDLINE]
  • Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury. Intensive Care Med. 2008;34:461–467 [MEDLINE]
  • Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011 Dec;39(12):2743-51 [MEDLINE]
  • Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364(16):1493 [MEDLINE]
  • Hyperosmolar therapy for raised intracranial pressure. N Engl J Med. 2012;367:746–752 [MEDLINE]
  • Traumatic intracranial hypertension. N Engl J Med. 2014;370:2121–2130. doi: 10.1056/NEJMra1208708 [MEDLINE]
  • High-osmolarity saline in neurocritical care: systematic review and meta-analysis.  Crit Care Med  2013;41:1353–1360.  doi: 10.1097/CCM.0b013e31827ca4b3 [MEDLINE]

Management of Seizures

  • Anti-epileptic drugs for preventing seizures following acute traumatic brain injury. Cochrane Database Syst Rev. 2001;(4):CD000173 [MEDLINE]

Management of Serum Glucose

  • Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg. 1991;75(4):545 [MEDLINE]
  • The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery. 2000;46(2):335 [MEDLINE]
  • The impact of hyperglycemia on patients with severe brain injury. J Trauma. 2005;58(1):47 [MEDLINE]

Management of Body Temperature

  • Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg. 2002;97(2):326 [MEDLINE]

Therapeutic Hypothermia

  • Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001;344:556 [MEDLINE]
  • Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet 2008;371:1955 [MEDLINE]
  • Hypothermia for traumatic head injury. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD001048. DOI: 10.1002/ 14651858.CD001048.pub4 [MEDLINE]
  • Prophylactic hypothermia for traumatic brain injury: a quantitative systematic review.  CJEM 2010; 12:355-364 [MEDLINE]
  • Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study:  Hypothermia II): a randomised trial.  Lancet Neurol  2011; 10:131-139 [MEDLINE]
  • Therapeutic hypothermia for the management of intracranial hypertension in severe traumatic brain injury: a systematic review.  Brain Inj  2012; 26:899-908 [MEDLINE]
  • Therapeutic hypothermia for acute brain injuries. Scand J Trauma Resusc Emerg Med. 2015 Jun 5;23:42. doi: 10.1186/s13049-015-0121-3 [MEDLINE]