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Traumatic Brain injury...The evidence based management



Brain Trauma Foundation (BTF) Guidelines first published in 1995 and then  in third (2007) edition – consequent 50% reduction in mortality
  • Primary injury is potentially preventable but irreversible
  • Secondary injury is our focus
BP and oxygenation
·  maintain SBP>90mmHg (level II)
·  single episodes of hypotension double the mortality
·  hypertonic fluids decrease fluid requirements and increase BP, but there is no morbidity/mortality outcome improvement
·  Maintain PaO2 >60mmHg or SpO2 >90% (Level III)
Hyperosmolar therapy (eg mannitol)
·  is effective for improving ICP, CPP, CBF (Level III)
·  Mannitol should be restricted to patients who have intracranial pressure monitoring, or those with signs of progressive deterioration or transtentorial herniation
·  Can buy time waiting for CT/OT
·  3 studies showed that hypertonic saline improved ICP in patients refractory to mannitol
Prophylactic Hypothermia
  • Patients are more likely to have favourable neurological outcomes (level III)
  • Longer duration (3-5 days) looks better
  • Eurotherm3235 Trial will hopefully answer the remaining questions
Infection prophylaxis
·  Increased incidence of infections with invasive ventilation and monitoring
·  Prophylactic antibiotics DO NOT reduce infections
·  More resistant infections emerge with prophylaxis
DVT prophylaxis
·  Increased incidence of DVT in TBI
·  Intermittent pneumatic stockings in combination with anticoagulation are indicated (level III)
·  Anticoagulation only instituted 24 hours post injury/surgery
ICP monitoring
·  Useful in predicting outcomes and guiding therapy
·  ICP>20mmHg is an indication for treatment (Level II)
·  ICP should be monitored in all patients with GCS <9 or abnormal CT
·  Prophylactic treatment (barbiturates/hypoventilation/paralysis/etc) of ICP without monitoring is not without risk
·  CPP target = 50-70mmHg
·  CPP < 50mmHg is assosciated with high mortality (level III)
Anaesthetics/analgesics/sedatives
·  No real difference in outcomes either way
·  Pain, agitation, etc can raise ICP
·  Barbiturates have cerebroprotective effects, but cause hypotension if used injudiciously
·  No significant difference between propofol and benzodiazepines
·  Morphine is good for analgesia, but has little sedative effect (duh)
·  Beware rebound ICP with reversal of morphine with naloxone
Post-traumatic seizures
·  Multiple risk factors
·  Anticonvulsants are indicated to decrease the incidence of early PTS (level II)
·  Early PTS does not indicate worse outcomes
·  Valproate may be associated with higher mortality
Hyperventilation
  • Prophylactic hyperventilation NOT recommended (level III)
  • Temporising measure only (to buy time)
  • If hyperventilation is used, SjO2 or PbrO2 monitoring should also be employed
Steroids – NO ROLE. High dose steroids have INCREASED MORTALITY
Decompressive craniotomy
·  Associated with improved outcomes in selected patients
·  Early CT scan and neurosurgery consult is imperative
In Summary
·  Head up 30 degrees
·  Maintain SBP > 90mmHg
·  PaO2 > 60mmHg
·  Early ICP monitoring
·  No hyperventilation
·  PaCO2 35-40mmHg
·  Manage pain and anxiety
·  Antiseizure prophylaxis
·  Keep an eye on therapeutic hypothermia
  • Decompressive craniotomy where indicated and skills allow
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