Last updated March 14, 2022

Management of Severe Traumatic Brain Injury

RECOMMENDATIONS

Treatment

Decompressive craniectomy (DC)

Bifrontal DC is not recommended to improve outcomes as measured by the GOS-E score (Glasgow Outcome Scale—Extended) at 6 mo post-injury in severe traumatic brain injury (TBI) patients with diffuse injury (without mass lesions), and with , intracranial pressure (ICP) elevation to values >20 mm Hg for more than 15 min within a 1-h period that are refractory to first-tier therapies. However, this procedure has been demonstrated to reduce ICP and to minimize days in the intensive care unit (ICU). (Level IIA)
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A large frontotemporoparietal DC (not less than 12 x 15 cm or 15 cm diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurologic outcomes in patients with severe TBI. (Level IIA)
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Prophylactic hypothermia

Early (within 2.5 h), short-term (48 h post-injury), prophylactic hypothermia is not recommended to improve outcomes in patients with diffuse injury. (Level IIB)
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Hyperosmolar therapy

Mannitol is effective for control of raised ICP at doses of 0.25 to 1 g/kg body weight. Arterial hypotension (systolic blood pressure <90 mm Hg) should be avoided. ()
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Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurologic deterioration not attributable to extracranial causes. ()
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Cerebrospinal fluid drainage

An external ventricular drainage (EVD) system zeroed at the midbrain with continuous drainage of cerebrospinal fluid (CSF) may be considered to lower ICP burden more effectively than intermittent use. (Level III)
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Use of CSF drainage to lower ICP in patients with an initial GCS <6 during the first 12 h after injury may be considered. (Level III)
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Ventilation therapies

Prolonged prophylactic hyperventilation with PaCO2 of ≤25 mm Hg is not recommended. (Level IIB)
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Hyperventilation is recommended as a temporizing measure for the reduction of elevated ICP. ()
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Hyperventilation should be avoided during the first 24 h after injury when cerebral blood flow (CBF) often is reduced critically. ()
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If hyperventilation is used, jugular venous oxygen saturation (SjO2) or (BtpO2) measurements are recommended to monitor oxygen delivery. ()
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Anesthetics, analgesics, and sedatives

Administration of barbiturates to induce burst suppression measured by electroencephalogram (EEG) as prophylaxis against the development of intracranial hypertension is not recommended. (Level IIB)
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High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy. (Level IIB)
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Although propofol is recommended for the control of ICP, it is not recommended for improvement in mortality or 6-month outcomes. Caution is required as high-dose propofol can produce significant morbidity. (Level IIB)
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Steroids

The use of steroids is not recommended for improving outcome or reducing ICP. In patients with severe TBI, high-dose methylprednisolone was associated with increased mortality and is contraindicated. (Level I)
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Nutrition

Feeding patients to attain basal caloric replacement at least by the fifth day and at most by the seventh day post-injury is recommended to decrease mortality. (Level IIA)
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Transgastric jejunal feeding is recommended to reduce the incidence of ventilator-associated pneumonia. (Level IIB)
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Infection prophylaxis

Early tracheostomy is recommended to reduce mechanical ventilation days when the overall benefit is thought to outweigh the complications associated with such a procedure. However, there is no evidence that early tracheostomy reduces mortality or the rate of nosocomial pneumonia. (Level IIA)
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The use of PI oral care is not recommended to reduce ventilator-associated pneumonia and may cause an increased risk of acute respiratory distress syndrome. (Level IIA)
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Antimicrobial-impregnated catheters may be considered to prevent catheter-related infections during external ventricular drainage. (Level III)
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Deep vein thrombosis prophylaxis

Low molecular weight heparin (LMWH) or low-dose unfractioned heparin may be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage. (Level III)
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In addition to compression stockings, pharmacologic prophylaxis may be considered if the brain injury is stable and the benefit is considered to outweigh the risk of increased intracranial hemorrhage. (Level III)
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There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis. (Level III)
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Seizure prophylaxis

Prophylactic use of phenytoin or valproate is not recommended for preventing late posttraumatic seizures (PTS). (Level IIA)
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Phenytoin is recommended to decrease the incidence of early PTS (within 7 d of injury), when the overall benefit is thought to outweigh the complications associated with such treatment. However, early PTS have not been associated with worse outcomes. (Level IIA)
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At the present time there is insufficient evidence to recommend levetiracetam compared with phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity. ()
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Monitoring

Intracranial pressure monitoring

Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality. (Level IIB)
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ICP should be monitored in all salvageable patients with a TBI (GCS 3-8 after resuscitation) and an abnormal computed tomography (CT) scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns. ()
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ICP monitoring is indicated in patients with severe TBI with a normal CT scan if ≥2 of the following features are noted at admission: age >40 years, unilateral or bilateral motor posturing, or SBP <90 mm Hg. ()
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Cerebral perfusion pressure monitoring

Management of severe TBI patients using guidelines-based recommendations for CPP monitoring is recommended to decrease 2-wk mortality. (Level IIB)
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Advanced cerebral monitoring

Jugular bulb monitoring of arteriovenous oxygen content difference (AVDO2), as a source of information for management decisions, may be considered to reduce mortality and improve outcomes at 3 and 6 mo post-injury. (Level III)
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Thresholds

Blood pressure thresholds

Maintainingsystolic blood pressure ( SBP) at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg or above for patients 15 to 49 or >70 years old may be considered to decrease mortality and improve outcomes. (Level III)
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Intracranial pressure thresholds

Treating ICP >22 mm Hg is recommended because values above this level are associated with increased mortality. (Level IIB)
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A combination of ICP values and clinical and brain CT findings may be used to make management decisions. (Level III)
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Cerebral perfusion pressure thresholds

The recommended target CPP value for survival and favorable outcomes is between 60 and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum optimal CPP threshold is unclear and may depend upon the autoregulatory status of the patient. (Level IIB)
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Avoiding aggressive attempts to maintain cerebral perfusion pressure (CPP) >70 mm Hg with fluids and pressors may be considered because of the risk of adult respiratory failure. (Level III)
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Advanced cerebral monitoring thresholds

Jugular venous saturation of <50% may be a threshold to avoid in order to reduce mortality and improve outcomes. (Level III)
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Recommendation Grading

Overview

Title

Management of Severe Traumatic Brain Injury

Authoring Organization

Publication Month/Year

September 20, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Paramedic emt

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D000070642 - Brain Injuries, Traumatic

Keywords

Severe traumatic brain injury, coma, Neurotrauma, TBI

Source Citation

Nancy Carney, PhD, Annette M. Totten, PhD, Cindy O'Reilly, BS, Jamie S. Ullman, MD, Gregory W.J. Hawryluk, MD, PhD, Michael J. Bell, MD, Susan L. Bratton, MD, Randall Chesnut, MD, Odette A. Harris, MD, MPH, Niranjan Kissoon, MD, Andres M. Rubiano, MD, Lori Shutter, MD, Robert C. Tasker, MBBS, MD, Monica S. Vavilala, MD, Jack Wilberger, MD, David W. Wright, MD, Jamshid Ghajar, MD, PhD, Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, Neurosurgery, Volume 80, Issue 1, January 2017, Pages 6–15, https://doi.org/10.1227/NEU.0000000000001432