Traumatic Brain Injury (TBI)

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Neuro Critical Care - TBI

Blood Pressure Management

·       While avoidance of (systemic and intracranial) hypotension in the TBI patient is paramount in preventing secondary brain injury, care must also be taken to avoid significant systemic (and subsequent intracranial) hypertension. 

·       Target Blood Pressure Parameters:

         -Primary BP Goal: Maintain MAP >80.

         -Secondary BP Goal: If MAP>80, then maintain SBP <160.

 

References on BP Management

·       American College of Physicians. (2015). Best practices in the management of traumatic brain injury.  American College of Surgeons. (2015). Best practices in the management of traumatic brain injury.

·       Hemphill, J.C., Greenberg, S.M., Anderson, C.S., Becker, K., Bendok, B.R., Cushman, M.,Woo, D. (2015). Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

·       Rossaint, R., Bouillon, B., Cerny, V., Coats, T.J., Duranteau, J., Fernandez-Mondejar, E., Spahn, D.R. (2016). The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Critical Care, 20, 1-55. 

 

Resuscitation:

1.     Secondary injury usually occurs in the ICU.

2.     Hypotension is worse than Hypoxia.  Both together is usually fatal.

3.     Be aggressive with lines, ICP management, meds and IVF until blood products and source control to maintain CPP.

4.     SAFE TBI Trial:  Mortality nearly doubled when given albumin as primary resuscitation.  

5.     Use Normal Saline (avoid large quantities to prevent high chloride levels). Sodium bicarbonate or sodium acetate are other options. 

Indications for Repeat CT Head (usually performed around 6 hours after initial unless clinical change):

1.     Deterioration in neuro exam / GCS score

2.     Abnormal admission CT Head AND

a.     Unreliable or unobtainable neuro exam

b.     High ISS (>15, ‘severe and critical’)

3.     Presence of mass effect and unreliable/obtainable exam

4.     Patients on Vitamin K antagonism (Coumadin), direct thrombin inhibitor or factor Xa inhibitors

5.     Patients on Plavix or full-dose ASA should be considered for repeat CT Head, regardless of exam, if they require early restart of ASA/Plavix

Anticoagulated Patients:

CT Head for all trauma patients with known anticoagulation meds.

Reverse immediately if possible TBI and suspected anticoagulation.

 

If antiplatelet use, then give 1 unit of platelets unless operative TBI then give 2 units of platelets.

 

Anti-Seizure Prophylaxis

Levetiracetam (Keppra) has been shown to reduce the incidence of early Post-Traumatic Seizure (within 7 days) but is not recommended for preventing late seizures.  Treat for 7 days only unless a seizure occurs then refer to neurosurgery/neurology for longer therapy.

 

Hyperventilation

·       Prophylactic hyperventilation (PaCO2 < 25) is not recommended.  Avoid during the first 24 hours.

·       Maintain normocarbia (PaCO2 35-45)

·       If ICP > 25, consider PaCO2 30-35.  Refer to Tier 2 treatment.

·       Once initiated, PaCO2 should be maintained at this target, even if ICP improves with other therapies.

 

DVT Prophylaxis

·       DVT develops in 20-30% TBI pts without any prophylaxis.

·       SCD’s should be applied immediately.

·       LMWH after 24 hrs has small increased rate post-crani hemorrhage.

·       Consider VTE prophylaxis within 24-72 hours if low risk for progression and stable repeat CT head.

·       Consider IVC Filter if high risk for TBI progression especially if long bone fx or pelvic fx

 

Infection Prophylaxis

·       Peri-procedural antibiotics for intubation are recommended by the Brain Injury Foundation to reduce the incidence of pneumonia but this is not routine practice.

·       Routine ventricular catheter exchange to reduce infection in patients with EVD’s is not recommended.  ICP monitors and EVDs should be placed under sterile technique with one dose of a peri-procedural antibiotic.  Minimize manipulation and flushing.   Avoid accessing the EVD bag for CSF cultures.  Notify the neurosurgery team for assistance with the EVD.

·       Recommend vancomycin/cefepime/metronidazole for 7 days for open skull fx. 

 

Tracheostomy

·       If level of consciousness stays low, trach may facilitate vent separation and decrease risk of pneumonia

·       Relative contraindications:  High ICP, unstable, Severe ARF

·       Guidelines suggest considering ‘early’ trach by HD 8; though most patients can be identified as eligible and appropriately undergo trach much sooner. 

 

Nutrition

·       Initiate enteral nutrition as soon as possible. 

·       Attain full caloric replacement by day 7 post-injury.

                  

Steroids

Not recommended.  Increases mortality in moderate to severe TBI.

 

Prognosis / Withdrawal of Care:

·       In general, severe TBI pts should receive full treatment for at least 72 hours post-injury.

·       Withdrawal of Life-Saving Treatment within 72 hours should be weighed against the patient’s exam especially if brainstem findings and against the patient’s previously stated wishes.

·       Age alone should not be a valid reason for treatment-limiting decisions.

·       Caution when using prognostic models for individuals.

 

·       Patients with TBI should undergo standardized outcome assessment using the GOS-E at 6 months.

 

Propranolol:

·        In patients with severe TBI (head AIS >=3), propranolol has been shown to reduce mortality and improve functional outcome (Glasgow Outcome Scale-Extended, GOSE)

·       Dosing: 20mg q12h until discharge or for at least 10 days

·       Start when hemodynamics permit