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Guidelines for the Management
of Severe Traumatic Brain Injury
A joint initiative of:
The Brain Trauma Foundation
The American Association of Neurological Surgeons
The Joint Section on Neurotrauma and Critical Care
TBI - Epidemiology
• 60,000 ANNUAL TOTAL TBI DEATHS*
• 44,000 OCCUR AT SCENE OR IN E.R.
• 16,000 OCCUR AFTERWARDS
Challenge is to reduce mortality
and improve outcome.
*lower limit estimate
Sosin et al. JAMA 1995, 273:1778-1780
Secondary Injury
• In the past two decades, medical research has
demonstrated that all brain damage does not occur
at the moment of impact, but evolves over the
ensuing hours and days. This is referred to as
secondary injury.
• The injured brain is extremely vulnerable to
hypotension, hypoxia, and increased intracranial
pressure which are causes of secondary injury.
Survey of 219 hospital intensive care units in 45 states that
treated patients with severe head injury.
Centers %
Routine ICP monitoring (more in high volume centers) 28
Hyperventilation and osmotic diuretics routinely used
83
Aiming for PaCO2 < 25 mm Hg
29
Corticosteroids use more than half the time
64
Crit Care Med 23: 560-567, 1995
Findings
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ICP monitoring used infrequently
Severe hyperventilation
Use of steroids currently not indicated
Wide variability in practice
Significant Reductions in Mortality
and Morbidity
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Rapid transport to a trauma care facility
Prompt resuscitation
CT scanning
Prompt evacuation of significant intracranial
hematomas
• ICP monitoring and treatment
Guidelines for Management of Severe TBI
Objectives:
• STATE and DISSEMINATE the current scientific
evidence for the OPTIMAL management of TBI.
• Highlight issues for further RESEARCH and
CLINICAL TRIALS.
• Improve OUTCOME.
Guidelines for the Management
of Severe Traumatic Brain Injury
Authors
Ross Bullock
Randall Chesnut
Guy Clifton
Jamshid Ghajar
Donald Marion
Jack Wilberger
Raj Narayan
David Newell
Lawrence Pitts
Michael Rosner
Beverly Walters
History
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11 authors and 14 topics
3 years of meetings
Over 3000 articles reviewed
1st edition completed in 1995
2nd edition completed in 1999
Funded and supported by the
Brain Trauma Foundation (BTF)
Advisory Committee
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Mark Dearden, M.D.
Robert Florin, M.D.
Andrew Jagoda, M.D.
James P. Kelly, M.D.
Andrew Maas, M.D.
Anthony Marmarou, Ph.D.
J. Douglas Miller, M.D.
Advisory Committee
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Peter C. Quinn
Jay Rosenberg, M.D.
Franco Servadei, M.D.
Nino Stocchetti, M.D.
Graham Teasdale, M.D.
Andreas Unterberg, M.D.
Hans von Holst, M.D.
Alex Valadka, M.D.
Topics
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Trauma Systems
Initial Management
Resuscitation of Blood Pressure and Oxygenation
Indications for ICP Monitoring
ICP Treatment Threshold
ICP Monitoring Technology
Cerebral Perfusion Pressure
Topics
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Hyperventilation
Mannitol
Barbiturates
Steroids
ICP Treatment Algorithm
Nutrition
Antiseizure Prophalyxis
Topic Chapter Format
I. Recommendations
A. Standards
B. Guidelines
C. Options
II.
III.
IV.
V.
VI.
VII.
VIII.
Overview
Process
Scientific Foundation
Summary
Key Issues for Future Investigation
Evidentiary Table
References
Guidelines for the Management
of Severe Traumatic Brain Injury
Topics list
• Electronic literature search (Medline)
• All relevant articles:
– Screened for scientific and statistical validity
– Classified according to a three point scale
• Class I
• Class II
• Class III
Guidelines for the Management
of Severe Traumatic Brain Injury
Class I
• Prospective, Randomized, Controlled Trials
Class II
• Non-Randomized, Prospective Controlled Trials
• Observational Studies
Class III
• Case Series
• Case Reports
• Expert Opinion
Guidelines for the Management
of Severe Traumatic Brain Injury
Standards
• Class I Evidence
Guidelines
• Class II Evidence
Options
• Class III Evidence
Guidelines for the Management
of Severe Traumatic Brain Injury
Standards
• Represent principles that reflect a high degree
of clinical certainty
Guidelines
• Represent principles that reflect a moderate degree
of clinical certainty
Options
• Represent principles for which there is unclear
clinical certainty
Guidelines for the Management
of Severe Traumatic Brain Injury
“The Spirit is Willing but the Data is Weak”
• State only what the literature supports
– First step toward standardizing head injury management
– Mandate for Class I studies
Trauma Systems
Guideline
• All regions in the United States should have an
organized trauma care system
• 1643 trauma patients treated at seven trauma
centers with differing annual volumes of trauma
patients.
• Patients taken to a low volume trauma center had
a 30% greater chance of dying.
J. Trauma 30: 1066-1076, 1990
Resuscitation of Blood Pressure
& Oxygenation
Guideline
• Hypotension (SBP < 90 mm Hg) or hypoxia
(apnea of cyanosis in the field or a PaO2 < 60 mm
Hg)
must be scrupulously avoided, if possible, or
corrected immediately.
Option
• The mean arterial pressure should be maintained
above 90 mm Hg throughout the patient’s course.
• Prospective prehospital and E.R. study of 717
severe head injury patients in the Traumatic Coma
Data Bank.
• Hypotension (SBP < 90 mm Hg) occurred in 35%
of patients and was associated with a two fold
increase in mortality.
J. Trauma 34:216-222, 1993
Initial Management
Option
• The first priority for the head injured patient is
complete and rapid physiologic resuscitation.
No specific treatment should be directed at
intracranial hypertension in the absence of signs
of transtentorial herniation or progressive
neurologic deterioration not attributable to
extracranial explanations.
• CBF measured in 35 severely head injured patients
with Xe-CT at, on average, 3 hours after injury.
• Global or regional ischemia (CBF < 18 ml/100
gm/min) observed in 31% patients.
• Global ischemia was measured in 57% of patients
with diffuse swelling.
J. Neurosurg 77: 360-368, 1992
Indications for ICP Monitoring
Guideline
• ICP monitoring is appropriate in severe head injury
patients with an abnormal CT, or a normal CT scan if
2 or more of the following are noted on admission:
– SBP < 90 mm Hg
– Age > 40 years
– Uni-/Bilateral motor posturing
• 207 severely head injured patients who had ICP monitoring
and head CT scans
• Patients with a normal head CT had a 13% chance of ICP >
20 mm Hg
• Risk of intracranial hypertension (with normal CT) increased
to 60% if two or more of the following were noted:
– 1) Age over 40 years
– 2) SBP < 90 mm Hg
– 3) motor posturing
J. Neurosurg 56: 650-659, 1982
ICP Monitoring Technology
Recommendation
• In the current state of technology, the ventricular
catheter connected to an external strain gauge is
the most accurate, low cost, and reliable method
of monitoring ICP. It also allows therapeutic
CSF drainage.
• ICP transduction via fiberoptic or strain gauge
devices placed in ventricular catheters provide
similar benefits but at a higher cost.
CT Scan
ICP Treatment Threshold
Guideline
• ICP treatment should be initiated at an upper
threshold of 20 - 25 mm Hg.
• The ICP threshold that was most predictive of 6 month
outcome was analyzed in 428 severely head injured patients.
• The proportion of hourly ICP reading greater than 20 mm Hg
was a significant independent determinant of outcome.
J. Neurosurg 75:S59-S66, 1991
Cerebral Perfusion Pressure
Option
• Cerebral Perfusion Pressure should be
maintained at a minimum of 70 mm Hg.
• 158 patients with GCS < 7 managed according to a
CPP protocol:
– Maintain euvolemia (CVP 8-10 mm Hg)
– Ventriculostomy CSF drainage at 15 mm Hg
– Systemic vasopressors to maintain CPP at least 70 mm Hg
– Hyperventilation, barbiturates, hypothermia not used.
• Mortality 29% and 2% vegetative for entire group. Favorable
outcome in GCS 3 of 35% ranging up to 75% for GCS 7.
J. Neurosurg 83: 949-962, 1992
Hyperventilation
Standard
• In the absence of increased intracranial pressure (ICP), chronic
prolonged hyperventilation therapy (PaCO2 of 25 mm Hg or less)
should be avoided after severe traumatic brain injury (TBI).
Guideline
• The use of prophylactic hyperventilation (PaCO2 < 35 mm Hg)
therapy during the first 24 hours after severe TBI should be
avoided because it can compromise cerebral perfusion during a
time when cerebral blood flow (CBF) is reduced.
Option
• Hyperventilation therapy may be necessary for brief periods when
there is acute neurologic deterioration, or for longer periods if there
is intracranial hypertension refractory to sedation, paralysis,
cerebrospinal fluid (CSF) drainage, and osmotic diuretics.
• A randomized prospective clinical trial in 113 patients to
study the effect of hyperventilation (PaCo2 25 mm Hg)
compared to normal ventilation (PaCo2 35 mm Hg) in
patients with similar severe head injury.
• Significantly fewer patients made a good recovery at
3 and 6 months post injury who had a GCS 6 or 7
on admission.
“PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION FOR A PERIOD
OF 5 DAYS RETARDS RECOVERY FROM SEVERE HEAD INJURY.”
J. Neurosurg 75:731-739, 1991
Mannitol
Guideline
• Mannitol is effective for control of raised ICP after
severe head injury.
Option
• Effective doses range from 0.25 - 1.0 gm/kg
body weight.
Mannitol
Option
• The indications for the use of mannitol prior to ICP
monitoring are signs of transtentorial herniation or
progressive neurological deterioration not
attributable to systemic pathology.
• However, hypovolemia should be avoided by
fluid replacement.
Barbiturates
Guideline
• High-dose barbiturate therapy may be considered
in hemodynamically stable salvagable severe head
injury patients with intracranial hypertension
refractory to maximal medical and surgical ICP
lowering therapy.
• A prospective trial of 73 patients with severe head injury and
medically refractory intracranial hypertension, randomized to
receive either a regimen including high-dose pentobarbital or
similar regiment without pentobarbital.
• Refractory intracranial hypertension occurred in only 12%
of the original severe head injury group (925 Patients).
• The chance of survival for those patients whose ICP
decreased(ICP < 20 mm Hg) with barbiturate treatment
was 92% compared to 17% when it did not.
J. Neurosurg 69:15-23, 1988
Steroids
Standard
• The use of steroids is not recommended for
improving outcome or reducing intracranial pressure
in patients with severe head injury.
• Prospective randomized trial in 300 patients
receiving dexamethasone (total IV dose within
51 hours of injury = 2.3 grams IV) versus placebo.
• No difference in outcome examined serially within
one year after treatment.
Zentralbl Neurochir 55:135-143, 1994
Antiseizure Prophylaxis
Standard
• Prophylactic use of phenytoin, carbamazepine,
phenobarbital or valproate is not recommended
for preventing late post-traumatic seizures.
• 404 post traumatic head injury patients (GCS 3-10 and
abnormal head CT) randomized to treatment with phenytoin
or placebo for one year with a two year follow up.
• In the first week after injury 4% of the patients receiving
phenytoin had seizures compared to 14% taking placebo.
• After the first week there was no significant difference
between the rate of seizures in the two groups.
N. Engl. J. Med 323:497-502, 1990
Nutrition
Guideline
• Replacement of 140% of Resting Metabolic
Expenditure in non-paralyzed patients and
100% Resting Metabolic Expenditure in
paralyzed patients using enteral or parenteral
formulas containing at least 15% of calories as
protein by the seventh day after injury.
• Prospective trial in 38 patients randomly assigned to
receive total parenteral nutrition (TPN) or standard
enteral nutrition (SEN).
• The TPN group got full nutritional support by 7 days
whereas the SEN group did not. There were significantly
more deaths in the group that did not receive full caloric
replacement by the 7th day after injury.
J. Neurosurg 58:907-912, 1983
ICP Treatment Algorithm
Option
• An algorithm, developed by consensus, is
presented. It should be viewed as “expert opinion”
and used as a framework which may be useful in
guiding an approach to treating intracranial
hypertension.
Critical Pathway for Treatment of Intracranial
Hypertension in the Severe Head Injury Patient
(Treatment Option)
Insert ICP Monitor
Maintain CPP  70 mmHg
YES
NO
Intracranial Hypertension?*
Ventricular Drainage (if available)
YES
Consider
Repeating
CT Scan
Intracranial Hypertension?
NO
May Repeat Mannitol
if Serum Osmolarity
< 320 mOsm/L &
Pt euvolemic
Mannitol (0.25 - 1.0 g/kg IV)
YES
Intracranial Hypertension?
Carefully
Withdraw
ICP Treatment
NO
Hyperventilation to PaCO2 30 - 35 mmHg
YES
Other Second
Tier Therapies
Intracranial Hypertension?
High Dose
Barbiturate therapy
NO
• Hyperventilation to PaCO2 < 30 mmHg
• Monitoring SjO2, AVDO2, and/orCBF
Recommended
Second Tier Therapy
*Threshold of 20-25 mmHg may be used. Other values may be substituted in individual conditions.
Guidelines for the Management of
Severe Traumatic Brain Injury
To place an order call:
Brain Trauma Foundation
@ 1-212-772-0608
fax 1-212-772-0357
www. braintrauma.org