ROYAL PERTH HOSPITAL

INTENSIVE CARE MANAGEMENT OF SEVERE TRAUMATIC

BRAIN INJURIES (TBI)

RPH HEAD INJURY DATA

There were 119 admissions to the ICU at RPH for head trauma for the year 2006.
Fifty-two (44%) had isolated head ± facial injuries only. Thirty-seven patients (31%)
had associated major or minor spinal trauma. One hundred sixteen patients (98%)
required mechanical ventilation, 59 (50%) required ICP monitoring. Twenty-four
patients (20%) died in hospital and 23% were discharged home.

GENERAL MANAGEMENT GOALS

Prevention of Secondary Traumatic Brain Injury (TBI). Rapid correction of

physiological abnormalities that have powerful adverse effects on outcome in
traumatic brain injury: hypoxaemia, hypotension, hypercapnia, hypo-osmilality,
hyperglycaemia and hyperpyrexia.

Manage Acutely Raised ICP: pharmacologically, surgically, physiologically.

Minimize Risk of Complications of Therapy and Prolonged Coma.

ICU ADMISSION CRITERIA.

Most admissions occur from the Emergency Department via CT scanner or Operating
Suite. Head injured patients are usually accommodated in the ICU, however HDA or
the State Major Trauma Unit (SMTU) may be utilized in rare circumstances. Criteria
for admission include:

1. Isolated Head Injury with post resuscitation GCS<8 in the absence of obvious
drug or alcohol intoxication. It is anticipated that most of these patients will be
intubated.

2. Head and Other Injuries with GCS< 12.

3. Need for ICP monitoring

4. Need for intubation, ventilation, inotropic support, complex fluid balance issues

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
ICP MONITORING

Utility:

Allows for prediction of outcome, detection of deteriorating intracranial pathology in

sedated patients, calculation of cerebral perfusion pressure (CPP), and allows
therapeutic CSF drainage (external ventricular catheter only).

Indications:

- All salvageable patients with severe TBI with GCS<8 with an

abnormal CT scan (hematomas, contusions, oedema, signs of
herniation or basal cistern compression).

- Consider ICP monitor in TBI with GCS<8 with normal CT scans if

age >40years and uni or bilateral motor posturing (Level 3
evidence).

Devices.

- Ventricular catheter: a ventricular catheter attached to a fluid

column and pressure transduction/closed drainage system (EVD) is
the reference standard for ICP measurement and allows CSF
drainage and in-situ recalibration.

- Intraparenchymal Monitors (“Codman”): These are the most

common systems used in TBI currently. State-of-the-art monitors
using dry micro strain transducers have negligible zero-drift but
cannot be recalibrated once inserted.

- Adjunctive monitoring: eg SjvO2, brain tissue pO2 are not used

routinely as there is insufficient data surrounding their use and
efficiency.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
SUPPORTIVE MEASURES

1. Cardio-Respiratory.

Airway :
- Tracheal intubation is indicated for airway
protection or need for mechanical ventilation.

- Appropriate spinal precautions must be taken

during airway manipulation.

Ventilation:
- Normocapnia (pCO2 35-40mmHg)

- Normoxia (pO2>75mmHg and SpO2>

95%).

- Prophylactic hyperventilation is NOT

recommended.

- Monitor: ABG, SpO2, ETCO2

- Chest Physio: commence when clinically

indicated and patient has stable ICP.

Circulation:

- Cerebral perfusion pressures 60-70mmHg

(Level 2 evidence). CPP<50mmHg and
SBP<90mmHg should be avoided at all
times (Level 2 evidence). Raising
CPP>70mmHg does not appear to confer
benefit but increases risks of acute lung
injury.

- CPP=MAP-ICP: measured from the

phlebostatic axis and the foramen of Munroe
respectively.

- Central venous catheterization and arterial

catheter is routine.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
2. Positioning
- Head up 30 degrees.
- Neck in neutral position to avoid venous
congestion
- Use sand-bags instead of collar for neck
stabilization if needed.
- Side-back-side positioning every 8 hours
unless ICP >25mmHg

3. Sedation:

Patients should be routinely sedated to suppress spontaneous movements and

sympathetic overactivity.
- Morphine 50mg with midazolam 50mg in
50ml via syringe pump is the preferred
sedative mixture. If more than 10mg /hour of
morphine is infused then the midazolam
component can be doubled to 100mg/50ml
or a separate infusion commenced
(preferable).

- Propofol infusion can be used for short

periods if early desedation for clinical
assessment is planned. Alternatively it can
be used as second line sedation in those
patients requiring > 10ml/hr of
morphine/midazolam solution.

- Barbiturates are not used prophylactically

- Paralysis with non-depolarizing muscle

relaxants is not used routinely but may be
required for acute ICP control (see later)

4. Anticonvulsant therapy:

Anticonvulsants are indicated to decrease the seizure risk in the early post traumatic
period (first seven days). Routine prophylaxis is not recommended after this period.

- Phenytoin load 10-15mg/kg by slow IV

injection (if not already done pre-ICU).
Appropriate maintenance dose once daily
should target corrected phenytoin levels 15-
20mmol/l. Corrected level=(40/albx
measured)
- Alternative anticonvulsants include
carbamazepine or valproate.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
5. Electrolyte management:

Goal to maintain relative hypertonicity to prevent worsening cerebral oedema.

- Serum Na+ targeted to 145-150mM.

- Avoid hypotonic fluids eg. 5% Dextrose.

Use 0.9% saline for maintenance fluid if
required.

- Consider infusion of hypertonic saline (20%

saline) via central line up to 10ml/hr to
achieve Na+ goal.

- Na+ and plasma should be measured at least

2-hourly while on hypertonic saline infusion.

- Concurrent urine and plasma osmolality

should be measured to confirm presence of
diabetes insipidus if suspected.

- Pitressin infusion (1 unit in 50ml 5%

Dextrose) starting at 1-2 ml/hr initially may
be used to treat diabetes insipidus. Careful
dose titration to urine output is required.

6. GI-Nutrition
- A gastric tube is placed as soon as
practicable. Orogastric intubation is
indicated in those with a skull base fracture
that may predispose to meningitis (eg frontal
plate/ethmoid/sphenoid injury). In some
patients with petrous temporal skull base
fractures it may be safe to have a
nasogastric tube. This must be discussed
with the neurosurgical team.

- Enteral nutrition is commenced as soon as

possible.

- Distal feeding tubes are required in heavily

sedated patients with consequent gastric
aspirates regularly in excess of 300ml 4
hourly.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
 - Stress Ulcer prophylaxis with esomeprazole
40mg daily

- Regular aperients are essential. Coloxyl and

Senna 2 tabs BD and parachoc 20 ml BD +/-
suppositories as needed.

7. Temperature Control:

Pyrexia is common in TBI patients especially those with intraventricular blood loads.
Current evidence is insufficient to support routine use of prophylactic hypothermia in
TBI. There may be some benefit of hypothermia in late neurological outcomes.

- Attempt to maintain core temperature 36-

37.5C

- If temperature exceeds 38.5C and is

associated with a rise in ICP to >20mmHg
then active cooling should be instituted. This
may include increasing sedation, use of
muscle relaxants and surface cooling
techniques.

8. DVT Prophylaxis:
- All patients should receive graduated
compression stockings and calf compression
devices. (Level 3 evidence).

- Prophylactic heparin is usually

contraindicated in the first days after TBI.
Liase with neurosurgery team daily to ensure
sc heparin is commenced as soon as is
deemed safe.

- Consider IVC filter placement in patients

unable to receive any prophylaxis (eg lower
limb injuries)

8. Infection Control

- There is no evidence to support prophylactic

antibiotics in TBI

- CSF catheters should preferably be inserted

in the operating room where practicable.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
 - Routine CSF sampling is carried out in
accordance with the unit protocol.

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation
 MANAGEMENT ALGORITHM FOR ACUTELY ELEVATED
ICP

Threshold for Treatment:

Generally an ICP>20mmHg sustained for > 10 minutes is a common threshold for

acute intervention. However, in reality the ICP intervention threshold is also
determined from clinical and brain CT findings. Certain patients may tolerate higher
ICPs.
ICP>20mmHg > 10 minutes

Ensure
- CPP 65-70mmHg
- SpO2>95%
- pC02<40mmHg
- Neck in neutral position

If no improvement in ICP Consider CT

- bolus sedation with opiate/benzo preparation scan.
Liase with
- consider bolus muscle relaxant neurosurgeon.
(vecuronium/rocuronium)

No improvement and signs of progressive

neurological deterioration or herniation.

- bolus thiopentone 125mg aliquots Urgent CT scan

repeated as necessary required
- hyperventilate temporarily
- consider mannitol 20% 0.25g-1g/kg IVI

If ICP remains elevated with no evidence of

surgical lesion on CT scan
- consider EVD
- decompressive craniectomy if suitable
- thiopentone infusion 150mg-250mg/hr

Compiled by Dr Cyrus Edibam, July 2008.

Ref : J Neurotrauma 2007:Vol 24, Supplement 1, Brain Trauma Foundation