Guidelines for the Management of Severe TBI, 3rd Edition
View the complete Guidelines, including methods and detailed evidence review here
The index of Guideline recommendations can be found below
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Blood pressure should be monitored and hypotension (systolic blood pressure < 90 mm Hg) avoided.
LEVEL III
Oxygenation should be monitored and hypoxia (PaO2 < 60 mm Hg or O2 saturation < 90%) avoided.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Mannitol is effective for control of raised intracranial pressure (ICP) at doses of 0.25 gm/kg to 1 g/kg body weight. Arterial hypotension (systolic blood pressure < 90 mm Hg) should be avoided.
LEVEL III
Restrict mannitol use prior to ICP monitoring to patients with signs of transtentorial herniation or progressive neurological deterioration not attributable to extracranial causes.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
There are insufficient data to support a Level II recommendation for this topic.
LEVEL III
Pooled data indicate that prophylactic hypothermia is not significantly associated with decreased mortality when compared with normothermic controls. However, preliminary findings suggest that a greater decrease in mortality risk is observed when target temperatures are maintained for more than 48 h.
Prophylactic hypothermia is associated with significantly higher Glasgow Outcome Scale (GOS) scores when compared to scores for normothermic controls.
Comment Regarding Classification of Level of Evidence for Meta-Analyses:
As stated in the Method Section of this guideline, to determine the recommendation level derived from a metaanalysis, three criteria are considered: (1) are all included studies of the same quality class, (2) are the findings of the studies in the same or contradictory directions, and (3) what are the results of sub-analyses that examine concerns about potential confounding factors? In this meta-analysis, although all included studies were Class II, the sub-analyses findings introduced sufficient concern about unknown influences to render the recommendation a Level III.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Periprocedural antibiotics for intubation should be administered to reduce the incidence of pneumonia. However, it does not change length of stay or mortality.
Early tracheostomy should be performed to reduce mechanical ventilation days. However, it does not alter mortality or the rate of nosocomial pneumonia.
LEVEL III
Routine ventricular catheter exchange or prophylactic antibiotic use for ventricular catheter placement is not recommended to reduce infection. Early extubation in qualified patients can be done without increased risk of pneumonia.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
There are insufficient data to support a Level II recommendation for this topic.
LEVEL III
Graduated compression stockings or intermittent pneumatic compression (IPC) stockings are recommended, unless lower extremity injuries prevent their use. Use should be continued until patients are ambulatory.
Low molecular weight heparin (LMWH) or low dose unfractionated heparin should be used in combination with mechanical prophylaxis. However, there is an increased risk for expansion of intracranial hemorrhage.
There is insufficient evidence to support recommendations regarding the preferred agent, dose, or timing of pharmacologic prophylaxis for deep vein thrombosis (DVT).
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Intracranial pressure (ICP) should be monitored in all salvageable patients with a severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score of 3-8 after resuscitation) and an abnormal computed tomography (CT) scan. An abnormal CT scan of the head is one that reveals hematomas, contusions, swelling, herniation, or compressed basal cisterns.
LEVEL III
ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or more of the following features are noted at admission: age over 40 years, unilateral or bilateral motor posturing, or systolic blood pressure (BP) < 90 mm Hg.
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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 intracranial pressure (ICP). It also can be recalibrated in situ. ICP transduction via fiberoptic or micro strain gauge devices placed in ventricular catheters provide similar benefits, but at a higher cost.
Parenchymal ICP monitors cannot be recalibrated during monitoring. Parenchimal ICP monitors, using micro strain pressure transducers, have negligible drift. The measurement drift is independent of the duration of monitoring.
Subarachnoid, subdural, and epidural monitors (fluid coupled or pneumatic) are less accurate.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Treatment should be initiated with intracranial pressure (ICP) thresholds above 20 mm Hg.
LEVEL III
A combination of ICP values, and clinical and brain CT findings, should be used to determine the need for treatment.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Aggressive attempts to maintain cerebral perfusion pressure (CPP) above 70 mm Hg with fluids and pressors should be avoided because of the risk of adult respiratory distress syndrome (ARDS).
LEVEL III
CPP of <50 mm Hg should be avoided.The CPP value to target lies within the range of 50-70 mm Hg. Patients with intact pressure autoregulation tolerate higher CPP values.
Ancillary monitoring of cerebral parameters that include blood flow, oxygenation, or metabolism facilitates CPP management.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
There are insufficient data to support a Level II recommendation for this topic.
LEVEL III
Jugular venous saturation (<50%) or brain tissue oxygen tension (<15 mm Hg) are treatment thresholds.
Jugular venous saturation or brain tissue oxygen monitoring measure cerebral oxygenation.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Prophylactic administration of barbiturates to induce burst suppression EEG is not recommended.
High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment. Hemodynamic stability is essential before and during barbiturate therapy.
Propofol is recommended for the control of ICP, but not for improvement in mortality or 6 month outcome. High-dose propofol can produce significant morbidity.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Patients should be fed to attain full caloric replacement by day 7 post-injury.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Prophylactic use of phenytoin or valproate is not recommended for preventing late posttraumatic seizures (PTS).
Anticonvulsants are indicated to decrease the incidence of early PTS (within 7 days of injury). However, early PTS is not associated with worse outcomes.
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LEVEL I
There are insufficient data to support a Level I recommendation for this topic.
LEVEL II
Prophylactic hyperventilation (PaCO2 of 25 mm Hg or less) is not recommended.
LEVEL III
Hyperventilation is recommended as a temporizing measure for the reduction of elevated intracranial pressure (ICP).
Hyperventilation should be avoided during the first 24hours after injury when cerebral blood flow (CBF) is often critically reduced.
If hyperventilation is used, jugular venous oxygen saturation (SjO2) or brain tissue oxygen tension (PbrO2) measurements are recommended to monitor oxygen delivery.
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LEVEL I
The use of steroids is not recommended for improving outcome or reducing intracranial pressure (ICP). In patients with moderate or severe traumatic brain injury (TBI), high-dose methylprednisolone is associated with increased mortality and is contraindicated.