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Guidelines for the

Management of
Severe Traumatic
Brain Injury 4th
Edition

Dr Babita Gupta
Professor, (JPNATC),
AIIMS, New Delhi
Introduction
Published in 2016 - Endorsed by Brain Trauma
Foundation, American Association of
Neurological Surgeons, Congress of Neurological
Surgeons
AIM: To have evidence-based recommendations
To encourage use of evidence-based treatments
that exist, & to encourage creativity in treatment
& research in areas where evidence doesn’t exist
Quality Assessment of Individual Studies
The study are classified as Class 1, 2, or 3
• Class 1: Good-quality randomized trials

• Class 2: Moderate-quality RCTs, good-quality


cohort, case-control studies

• Class 3: Low-quality RCTs, moderate to low-quality


cohort or case control studies, and case series and
other non-comparative designs
Level of Recommendation
The levels were primarily based on the
quality of the body of evidence as follows

• Level I : High-quality
• Level II A : Moderate-quality
• Level II B and III: Low-quality
Scope of the guideline
PART I: TREATMENTS

PART II: MONITORING

PART III: THRESHOLDS


PART I : TREATMENTS
DECOMPRESSIVE PROPHYLACTIC HYPEROSMOLAR CEREBROSPINAL
CRANIECTOMY HYPOTHERMIA THERAPY FLUID DRAINAGE

ANESTHETICS,
VENTILATION
ANALGESICS, AND STEROIDS NUTRITION
THERAPIES
SEDATIVES

DEEP VEIN
INFECTION SEIZURE
THROMBOSIS
PROPHYLAXIS PROPHYLAXIS
PROPHYLAXIS
Decompressive Craniectomy
 Cerebral edema
• Primary injury
• Secondary injury

 DC: Relieving elevated intracranial pressure

 Variations in
• Surgical techniques
• Timing
• Patient populations
Decompressive Craniectomy
Recommedations
 Level I
Insufficient evidence

Level II A
 Bifrontal DC is not recommended to improve outcomes as measured
by the Glasgow Outcome Scale–Extended (GOS-E) score at 6 months
post-injury in severe TBI patients with diffuse injury
 However, this procedure has been demonstrated to reduce ICP and to
minimize days in the intensive care unit (ICU)
 Hypothermia : Preserve cells and tissue

 Standard care for neuroprotection after cardiac arrest from acute


coronary syndromes

 Hypothermia bears risks


• Coagulopathy
• Immunosuppression
• Cardiac dysrhythmia
• Death
Hypothermia
 Prophylactic : Early after injury and prior to intracranial
pressure elevation
 Therapeutic : Treatment for refractory intracranial
pressure elevation
Prophylactic Hypothermia
Level I and II A
There was insufficient evidence
Level II B
Early (within 2.5 hours), short-term (48 hours
post-injury) prophylactic hypothermia is not
recommended to improve outcomes in patients
with diffuse injury
Hyperosmolar Therapy
 Dramatic change of the volume of the brain: Administration
of hypertonic or hypotonic intravenous solutions
 Hypertonic saline and Mannitol : Routinely employed
hyperosmolar agents
 Hypertonic saline
Central pontine myelinolysis in hyponatremic patients
 Mannitol
Diuretic effect is undesirable in hypotensive patient
Hyperosmolar Therapy
Recommendations
Level I, II, and III
 Although hyperosmolar therapy may lower ICP, there was insufficient
evidence about effects on clinical outcomes to support a specific
recommendation, or to support use of any specific hyperosmolar
agent, for patients with severe TBI
Hyperosmolar Therapy
Recommendations
Recommendations Mannitol is effective for control of raised ICP at doses of
from the Prior (3rd)
Edition not carried 0.25 - 1 g/kg body weight
forward Arterial hypotension (systolic BP <90 mm Hg) should be
avoided

Restrict mannitol use prior to ICP monitoring


-signs of transtentorial herniation
-progressive neurological deterioration
Cerebrospinal Fluid Drainage
 External ventricular drainage (EVD)
: controversy

 EVD
• Closed position: Monitor
intracranial pressure (CP)
• Open position: Drainage of CSF
Cerebrospinal Fluid Drainage
Recommendations
Level An EVD system zeroed at the midbrain
with continuous drainage of CSF may
III be considered to lower ICP burden
more effectively than intermittent use

Use of CSF drainage to lower ICP in


patients with an initial GCS <6 during
the 1st 12 hours after injury may be
considered
Ventilation Therapies
 Definitive airway often required in TBI patients

 The goal for severe TBI patients


• Normal ventilation and normal partial pressure of carbon dioxide
in arterial blood (PaCO2) ranges from 35-45 mm Hg

 Cerebral blood flow : The brain’s metabolic demands


• Low PaCO2 : Low CBF  cerebral ischemia
• High PaCO2 : Cerebral hyperemia  high ICP
Ventilation Therapies Recommendations
Level Prolonged prophylactic hyperventilation with
partial pressure of carbon dioxide in arterial
II B blood (PaCO2) of 25 mm Hg or less is not
recommended
Anesthetics, Analgesics, and Sedatives
 Important for prophylaxis or control of intracranial hypertension and
seizures

 Barbiturates have a long history of being used to control intracranial


pressure (ICP)

 Side effects: Hypotension and decreased cardiac output, increased


intrapulmonary shunting
Anesthetics, Analgesics, and Sedatives
Recommendations
Level Administration of barbiturates to induce
burst suppression as prophylaxis against
II B the development of intracranial
hypertension is not recommended
Anesthetics, Analgesics, and Sedatives
Recommendations
Level High-dose barbiturate administration is recommended
to control elevated ICP refractory to maximum
II B standard medical and surgical treatment
Anesthetics, Analgesics, and Sedatives
Recommendations
Level Although propofol is recommended for the control of
ICP, it is not recommended for improvement in
II B mortality or 6-month outcomes

Caution is required as high-dose propofol can


produce significant morbidity
Steroids
 Steroid useful in
• Restoration of altered vascular permeability in brain edema
• Reduction of CSF production
• Attenuation of free radical production

 Glucocorticoids benefit for patients with brain tumors when


administered in the perioperative period

 However, studies of severe TBI patients failed to find a benefit

 The Corticosteroid Randomization After Significant Head Injury Trial


(CRASH) trial was designed to provide high- quality evidence on the
impact of steroids on TBI patients
Steroids Recommendations

Level I Use of steroids not recommended for


improving outcome or reducing ICP

In patients with severe TBI, high-dose


methylprednisolone was associated with
increased mortality and is contraindicated
Nutrition Recommendations
Level II A
• 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 II B
• Transgastric jejunal feeding is recommended to reduce the
incidence of ventilator- associated pneumonia
Infection Prophylaxis
 Severe traumatic brain injury can increase a patient’s
susceptibility to infection
• Use of mechanical ventilation
• Invasive monitoring

 Patients undergoing intracranial pressure (ICP) monitoring


have related infection rates as high as 27%
Infection Prophylaxis Recommendations
Level Early tracheostomy is recommended to
reduce mechanical ventilation days when
II A the overall benefit is felt to outweigh the
complications associated with such a
procedure
No evidence that early tracheostomy
reduces mortality or the rate of
nosocomial pneumonia
Infection Prophylaxis Recommendations
Level The use of povidone-iodine (PI) oral care
is not recommended to reduce VAP and
II A may cause an increased risk of ARDS
Infection Prophylaxis Recommendations
Level Antimicrobial-impregnated catheters may
be considered to prevent catheter-related
III infections during EVD
Deep Vein Thrombosis Prophylaxis

 54% incidence of DVT without prophylactic treatment

 25% incidence in patients with isolated TBI treated with


sequential compression devices
Deep Vein Thrombosis Prophylaxis

 Significant risk for VTE due to


• Hypercoagulability resulting from the primary brain injury
• Prolonged periods of immobilization
• Focal motor deficits

 Non pharmacologic Vs Pharmacologic prevention


Deep Vein Thrombosis Prophylaxis
Recommendation
Level Low molecular weight heparin (LMWH) or
low-dose unfractioned heparin may be used
III in combination with mechanical prophylaxis.
However, there is increased risk for expansion
of intracranial hemorrhage
Deep Vein Thrombosis Prophylaxis
Recommendation

Level In addition to compression stockings, pharmacologic


prophylaxis may be considered if the brain injury is
III stable and the benefit > risk of increased intracranial
hemorrhage.
Insufficient evidence to support recommendations
regarding the preferred agent, dose, or timing of
pharmacologic prophylaxis for DVT
Seizure Prophylaxis
 Post-traumatic seizures (PTS) are classified as
• Early < 7 days of injury
• late > 7 days following injury

 Post-traumatic epilepsy (PTE) is defined as recurrent seizures


> 7 days following injury
Seizure Prophylaxis
Seizure prophylaxis for PTS refers to the practice of
administering anticonvulsants to patients following
TBI
Seizure Prophylaxis Recommendations
Level Prophylactic use of phenytoin or valproate
is not recommended for preventing late PTS
II A
Phenytoin is recommended to decrease the
incidence of early PTS (within 7 days of
injury)
Part II : Monitoring

Intracranial Pressure Cerebral Perfusion Pressure


monitoring monitoring

Advanced cerebral
monitoring
Intracranial pressure monitoring
Intracranial Pressure Monitoring
Recommendations
Management of severe TBI patient using
Level II B information from ICP monitoring is
recommended to reduce in-hospital and
2-week post-injury mortality
Cerebral Perfusion Pressure Monitoring

CPP = MAP – ICP

 MAP measured at the level of the heart


 ICP at the level of the foramina of Monro,
or the external auditory meatus
Cerebral Perfusion Pressure monitoring
Recommendations
Level CPP monitoring is recommended to
decrease 2-week mortality
IIB
Part III : Thresholds

Blood Pressure Intracranial


(BP) Pressure (ICP)

Cerebral Perfusion Advanced


Pressure Cerebral
Monitoring (CPP) Monitoring (ACM)
Blood pressure Threshold
Level SBP at ≥100 mm Hg for patients
III 50 to 69 years old
SBP ≥110 mmHg for patients 15 to
49 or over 70 years old to decrease
mortality and improve outcomes
Intracranial Pressure Recommendations
Level Treating ICP above 22 mm Hg is recommended
because values above this level are associated
II B with increased mortality (Level2B)
Intracranial Pressure Recommendations

Level Combination of ICP values and clinical and


brain CT findings may be used to make
III management decisions
Cerebral perfusion pressure (CPP)
Recommendations
Level CPP value for survival and favorable outcomes
is between 60 and 70 mm Hg
II B
Cerebral perfusion pressure (CPP)
Recommendations

Level Avoiding aggressive attempts to maintain CPP > 70


mm Hg with fluids and pressors may be considered
III because of the risk of adult respiratory failure
Advanced Cerebral Monitoring Thresholds
Recommendations
Level Jugular venous saturation of <50% may
be a threshold to avoid in order to reduce
III mortality and improve outcomes
Take Home Message
Ventilation therapy
• Prolonged prophylactic hyperventilation is not recommended

Anesthetic agent
• Administration of barbiturates as prophylaxis against the
development of intracranial hypertension is not recommended

• High-dose barbiturate administration is recommended to


control refractory elevated ICP

• Propofol is not recommended for improvement in mortality or


6-month outcomes
Take home massage
Monitoring

• Intracranial pressure monitor should be monitored but in low


technology setting CT scan and clinical examination can be used

• Cerebral perfusion pressure monitoring is recommended

• Jugular Bulb Monitoring of Arteriovenous Oxygen Content


Difference(AVDO2) monitoring is recommended to reduce
mortality
Take home massage
Thresholds
• SBP at ≥100 mm Hg for patients 50 to 69 years

• SBP ≥110 mm Hg for patients 15 to 49 or over 70 years old

• ICP > 22 mmHg should be treated

• CPP should be maintained 60-70 mmHg


• Aggressive volume and pressors to maintain CPP > 70 mmHg should be
avoided

• Jugular venous saturation of the brain <50% should be avoided


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