BEST PRACTICES IN
THE MANAGEMENT
OF TRAUMATIC
BRAIN INJURY
Table of Contents
Introduction. . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Using the Glasgow Coma Scale.. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Triage and Transport.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Goals of Treatment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Intracranial Pressure Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Management of Intracranial Hypertension.. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Advanced Neuromonitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Surgical Management.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Nutritional Support.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Tracheostomy.. .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Timing of Secondary Procedures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Timing of Pharmacologic Venous Thromboembolism Prophylaxis.. . . . . . . . . . . . . . . . . . . . . . . . 17
Management Considerations for Pediatric Patients with TBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Management Considerations for Elderly Patients with TBI.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Prognostic Decision-Making and Withdrawal of Medical Support. . . . . . . . . . . . . . . . . . . . . . . . . 20
Outcome Assessment and Quality Improvement in TBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Bibliography....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Expert Panel.. ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Acknowledgements.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Disclaimer.. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
INTRODUCTION
Traumatic brain injury (TBI) is a disease
process that carries major public health
and socioeconomic consequences. In
the United States alone, an estimated
2.5 million emergency department visits
and hospitalizations are associated with
TBI annually; and more than 50,000
individuals die from TBI. Moreover, a
considerable proportion of TBI survivors
incur temporary or permanent disability.
The estimated annual burden of TBI on
the United States economy is more than
$76 billion, with the costs for disability
and lost productivity outweighing
the costs for acute medical care.
Data from well-designed, controlled
studies on acute management of TBI are
sparse. Evidence-based guidelines for TBI
management have been compiled, but
the paucity of high-quality studies limits
the strength and scope of their counsel.
The TQIP Best Practice Guidelines for
the Management of Traumatic Brain
Injury present recommendations
regarding care of the TBI patients based
on the best available evidence or, if
evidence is lacking, based upon the
consensus opinion of the expert panel.
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Standardized approaches
to GCS assessment and
reporting are essential
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TRIAGE AND
TRANSPORT
Key Message
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GOALS OF TREATMENT
These clinical parameters should be
maintained as part of goal-directed TBI
treatment. Some of these goals are more
relevant for patients in the intensive care
unit (ICU) setting (e.g., CPP, ICP, PbtO2)
while others are applicable to all TBI
patients. Adequate oxygenation and
normocapnia should be maintained.
Patients with significant pulmonary
issues (e.g. Acute Respiratory Distress
Syndrome) may require lung-specific
parameters. Systolic blood pressure
(SBP) and mean arterial pressure
should be monitored closely to avoid
hypotension. The goal for temperature
management is normothermia. Core
body temperature should be kept
<38C. The goal for electrolytes is to
maintain within normal range. Specific
attention to the sodium level is crucial
in TBI patients. Hyponatremia must be
avoided as this may worsen cerebral
edema. TBI patients may also develop
diabetes insipidus (DI) or the syndrome
of inappropriate antidiuretic hormone
(SIADH). Therefore patients should
have frequent monitoring of the serum
sodium and osmolality levels. Both
ICP 20 - 25 mmHg
PbtO2 15 mmHg
INR 1.4
CPP 60 mmHg *
Temperature 36.0-38C
Hemoglobin 7 g/dl
PH 7.35-7.45
PaO2: partial pressure of oxygen; PaCO2: partial pressure of carbon dioxide; SBP: systolic blood
pressure; ICP: intracranial pressure; PbtO2: brain tissue oxygen tension; CPP: cerebral perfusion
pressure; INR: international normalized ratio; *depending on status of cerebral autoregulation
INTRACRANIAL
PRESSURE MONITORING
Key Messages:
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MANAGEMENT OF
INTRACRANIAL
HYPERTENSION
Key Messages
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TIER 1
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TIER 2
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weight). Caution should be taken in the hypovolemic patient when osmotic diuresis
is instituted with mannitol. The serum sodium and osmolality must be assessed
frequently (every 6 hours) and additional doses should be held if serum osmolality
exceeds 320 mOsm/L. Mannitol may also be held if there is evidence of hypovolemia
Hypertonic saline may be administered in intermittent boluses of 3% sodium
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TIER 3
(includes potential salvage therapies)
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Barbiturate or propofol (anesthesia dosage) coma may be induced for those patients
who have failed to respond to aggressive measures to control malignant intracranial
hypertension, however it should only be instituted if a test dose of barbituate or propofol
results in a decrease in ICP, thereby identifying the patient as a responder. Hypotension
is a frequent side effect of high dose therapy with these agents. Meticulous volume
resuscitation should be ensured and infusion of vasopressor/inotropes may be required.
Prolonged use or high dose of propofol can lead to propofol infusion syndrome.
Continuous EEG may be used to ensure targeting of the infusion to burst suppression
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ADVANCED
NEUROMONITORING
Key Messages
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Advanced neuromonitoring
and assessment of cerebral
autoregulation may be helpful in
identifying a more individualized
approach to treatment
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SURGICAL
MANAGEMENT
Key messages:
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Decompressive craniectomy is
effective in controlling intracranial
pressure, but uncertainty exists as
to its potential to improve outcome
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NUTRITIONAL SUPPORT
Key Messages:
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TRACHEOSTOMY
Key Messages:
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Relative contraindications
to tracheostomy include
high intracranial pressure,
hemodynamic instability, and
severe respiratory failure
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TIMING OF SECONDARY
PROCEDURES
Key Messages
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Laparoscopic procedures
should be avoided
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TIMING OF
PHARMACOLOGIC
VENOUS
THROMBOEMBOLISM
PROPHYLAXIS
Key Messages
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Moderate risk
High risk
No moderate or high
risk criteria
Consider placement of an
IVC filter*
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MANAGEMENT
CONSIDERATIONS
FOR PEDIATRIC
PATIENTS WITH TBI
Key Messages:
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MANAGEMENT
CONSIDERATIONS
FOR ELDERLY
PATIENTS WITH TBI
Key Messages:
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PROGNOSTITC
DECISION-MAKING
AND WITHDRAWAL OF
MEDICAL SUPPORT
Key Messages:
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OUTCOME ASSESSMENT
AND QUALITY
IMPROVEMENT IN TBI
Key messages:
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Bibliography
Introduction
Goals of Treatment
Advanced Neuromonitoring
24
Management of
Intracranial Hypertension
Surgical Management
Bullock RM, Chesnut R, Ghajar JBG, Gordon D, Hartl
R,Newell DW, Servadei, F, Walters, BC, Wilberger JE.
Guidelines for the Surgical Management of Traumatic
Brain Injury. Neurosurgery, Supplement, Volume 58,
Number 3. 2006.
Cooper DJ, Rosenfeld JV, et al. Decompressive
Craniectomy in Diffuse Traumatic Brain Injury. NEJM.
364:1493-1502. 2011
Nutritional Support
Hartl, R., et al., Effect of early nutrition on deaths due
to severe traumatic brain injury. J Neurosurg 109:50-6.
2008
Chiang, Y.H., et al., Early enteral nutrition and
clinical outcomes of severe traumatic brain injury
patients in acute stage: a multi-center cohort study. J
Neurotrauma,. 29:75-80. 2012
Wang, X., et al., Nutritional support for patients
sustaining traumatic brain injury: a systematic review
and meta-analysis of prospective studies. PLoS One,
8:e58838. 2013
Brain Trauma Foundation, American Association of
Neurological Surgeons; Congress of Neurological
Surgeons; Joint Section on Neurotrauma and Critical
Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J,
McConnell Hammond FF, Harris OA, Hartl R, Manley
GT, Nemecek A, Newell DW, Rosenthal G, Schouten J,
Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger
JE, Wright DW. Guidelines for the Management of
Severe Traumatic Brain Injury. XII. Nutrition.
J Neurotrauma. 24 Suppl 1:S77-82, 2007.
Dhaliwal R, Cahill N, Lemieux M, Heyland DK.
The Canadian critical care nutrition guidelines in
2013: an update on current recommendations and
implementation strategies. Nutr Clin Pract.,
29:29-43. 2014
Tracheostomy
Scales, D.C. and Ferguson, N.D. (2010). Early vs late
tracheotomy in ICU patients. JAMA : the journal of the
American Medical Association 303, 1537-1538.
Bouderka, M.A., Fakhir, B., Bouaggad, A., Hmamouchi,
B., Hamoudi, D. and Harti, A. (2004). Early tracheostomy
versus prolonged endotracheal intubation in severe
head injury. The Journal of trauma 57, 251-254.
Gomes Silva, B.N., Andriolo, R.B., Saconato, H.,
Atallah, A.N. and Valente, O. (2012). Early versus late
tracheostomy for critically ill patients. Cochrane
Database Syst Rev 3, CD007271.
25
Kwiatt ME, Patel MS, Ross SE, Lachant MT, MacNew HG,
Ochsner MG, Norwood SH, Speier L, Kozar R, Gerber JA,
Rowell S, Krishnakumar S, Livingston DH, Manis G, Haan
JM. Is low-molecular-weight heparin safe for venous
thromboembolism prophylaxis in patients with traumatic
brain injury? A Western Trauma Association Multicenter
study. J Trauma Acute Care Surg. 2012 Sep;73(3):625-8.
Levy 2010
26
Management Considerations
for Pediatric Patients With TBI
(2003). Guidelines for the acute medical management
of severe traumatic brain injury in infants, children, and
adolescents. Crit Care Med 31, S407-491.
Management Considerations
for Elderly Patients With TBI
Harvey L, Close J. Traumatic Brain Injury in Older Adults:
characteristics, causes and consequences. Injury;
43(2012)1821-1826.
Moorman ML, Nash JE, Stabi KL. Emergency surgery
and trauma in patients treated with the new oral
anticoagulants: dabigatran, rivaroxaban, and apixaban.
J Trauma Acute Care Surg. 2014 Sep;77(3):486-94.
Mack L, Chan S, Silva J, Hogan T. The use of head
computed tomography in elderly patients sustaining
minor head trauma. J Emerg Med 2003; 24:157-162.
Jagoda AS, Bazarian JJ, Bruns JJ Jr, et al; American
College of Emergency Physicians; Centers for Disease
Control and Prevention. Clinical policy: Neuroimaging
and decision-making in adult mild traumatic
brain injury in the acute setting. Ann Emerg Med
2008;52(6):714-748.
Utomo W, Gabbe B, Simpson P, Cameron P. Predictors of
in-hospital mortality and 6-month functional outcomes
in older adults after moderate o severe traumatic brain
injury. Injury 40(2009) 973-977.
Hukkelhoven C, Steyerberg E, Rampen A, et al. Patient
age and outcome following severe traumatic brain
injury: an analysis of 5600 patients. J Neurosurg. 2003;
99:666-673.
Livingston D, Lavery R; Mosenthal A, et al. Recovery at
One Year Following Isolated Traumatic Brain Injury: A
Western Trauma Association Prospective Multicenter
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Moorman ML, Nash JE, Stabi KL. Emergency surgery
and trauma in patients treated with the new oral
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J Trauma Acute Care Surg. 2014 Sep;77(3):486-594.
27
Expert Panel
Randeep Jawa, MD
Associate Professor of Surgery, Stony Brook
School of Medicine, Stony Brook NY
Todd Kilbaugh, MD
Associate Professor of Anesthesia, Critical Care,
and Pediatrics, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA
28
Jamie Ullman, MD
Associate Professor and Director of Neurotrauma
North Shore University Hospital, Manhasset, NY
J. Claude Hemphill, MD
Professor of Neurology, UCSF, Chief of Neurology,
San Francisco General Hospital, San Francisco, CA
Alex Valadka, MD
Chief of Neurosurgery
Seton Hospital, Austin, Texas
Michael Huang, MD
Assistant Professor of Neurosurgery, UCSF
San Francisco General Hospital, San Francisco, CA
David W. Wright, MD
Associate Professor, Department of Emergency
Medicine Emory University, Atlanta, GA
The Management of Intracranial Hypertension and Goals of Treatment sections were adapted
from the National Institute of Neurological Disorders and Stroke of the National Institutes of
Health funded (Award Numbers NS062778, 5U10NS059032, U01NS056975) ProTECT III clinical
trial protocol that was successfully implemented in 38 hospitals through the Neurological
Emergencies Treatment Trials network. The protocol was developed by the ProTECT III
Clinical Standardization Team (G. Manley, B. Aarabi, O. Harris, C. Hemphill, P. LeRoux, L. Merck,
R. Narayan, D. Okonkwo, J. Pascual, J. Salomone, W. Schwab, A. Valadka, D. Wright). The
ProTECT III protocol was based on the Brain Trauma Foundation Guidelines for the Treatment
and Surgical Management of TBI and refined with consensus-based methodology. We also
acknowledge the participation of members of the AANS/CNS Joint Section of Neurotrauma
and Critical Care (G.M., D.A., O.H., M.H., D.O., P.T., S.T., J.U., A.V.), the Neurocritical Care Society
(J.C.H., C.R.), and the American College of Emergency Medicine (D.W). The content is solely
the responsibility of the authors and does not necessarily represent the official views of the
National Institutes of Health or other supporting entities.
The intent of the ACS TQIP Best Practices Guidelines is to provide health care professionals
with evidence-based recommendations regarding care of the trauma patient. The Best
Practices Guidelines do not include all potential options for prevention, diagnosis, and
treatment and are not intended as a substitute for the providers clinical judgment and
experience. The responsible provider must make all treatment decisions based upon his or
her independent judgment and the patients individual clinical presentation. The ACS shall
not be liable for any direct, indirect, special, incidental, or consequential damages related
to the use of the information contained herein. The ACS may modify the TQIP Best Practices
Guidelines at any time without notice.
Notes
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