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

A Protocol Example &

Patient Case Study

TBI Patient Case Management

Resuscitation/Monitoring
Neurological Evaluation
Neurosurgical Treatment

TBI Patient Case Management

ICP Monitoring
Three Step ICP/CPP Management
Case Presentation and Management

Resuscitation
o

Iatrogenic 2 Injury (?)

Inadequate Fluid Resuscitation

Hypovolemia

Narcotic, Hypnotic, Diuretic

Hypotension
Cerebral Ischemia

Resuscitation
Arterial line - monitor blood pressure (MABP)
Central venous line - monitor CVP

maintain MABP 90 mm Hg
maintain CVP 5-10 mm Hg

Prevent
Hypotension

Neurological Exam
Eyes
Open spontaneously
Open to verbal command
Open to pain
No response

Best Verbal Response

4
3
2
1

Best Motor Response

Obeys commands
Localizes pain
Flexion-Withdrawal
Flexion-Abnormal
Extension
No response

6
5
4
3
2
1

Oriented and converses

Disoriented and converses
Inappropriate words
Incomprehensible Sounds
No response
Glasgow Coma Scale Total

5
4
3
2
1
3 -15

Neurological Exam

Neurological Exam
Pupil reactivity to light
positive reaction > 1mm constriction
Pupil asymmetry
significant asymmetry > 1mm difference

Neurological Exam

Neurosurgical Intervention
Consider Intracranial Mass Lesion Evacuation:
1) Extracerebral collection >1cm thick
2) Cerebellar lesion with brain stem mass effect
3) Anterior temporal lobe hemorrhagic contusion
with mass effect
4) Frontal/temporal mass lesion with intractable
ICP >25 mm Hg

Neurosurgical Treatment

Neurosurgical Treatment
Pre-op Scan:
Epidural and
parenchymal
hematomas

Neurosurgical Treatment
Post-op Scan:
Evacuation of
hematomas

Conservative Treatment
Left posterior
temporal lobe
hemorrhagic
contusion

Conservative Treatment
Bone plate
removal and
dural expansion
for Intracranial
Hypertension
Hemorrhagic
contusion not
evacuated

Conservative Treatment
Resolving Edema

Conservative Treatment
Two weeks later
Resolution of
edema

ICP Monitoring
INDICATION:
TYPE:

GCS < 8 , Traumatic Brain Injury

Ventricular catheter connected
to external strain gauge or
indwelling fiberoptic/strain gauge
INFECTION:
< 10% . Not usually clinically
significant
HEMORRHAGE: < 1% . Not usually clinically
significant

ICP Monitoring

Ventricle
Parenchymal
Subarachnoid
Subdural
Epidural

ICP Monitoring
Guided Placement
Placement of a ventricular catheter
At 90o to the scalp or skull can be
done even with slit ventricles.
A tripod device ensures a ninety
degree trajectory.

ICP Monitoring

A. Entry Site

B. AP View

Freehand Placement
The ventricular catheter is aimed
in the coronal plane toward the
nasion and in the parasagital
plane toward the tragus of the
ipsilateral ear.

C. Ventriculostomy
Tunnel under scalp

To monitor
Pressure transducer

Foramen of
Monro

Baylor College of Medicine 1990

ICP Monitoring
Measurement
If there is shift of the ventricles,
the ventricle catheter is placed
on the side of the shift. The
incision, twist drill hole and
catheter placement are done at
4cm lateral to the midline rather
than 3cm.

3 cm

10 cm

ICP Monitoring
Incision
A small 1cm incision can be done,
expediting the procedure.
The usual pre-operative antibiotic
prophylaxis can be given.

ICP Monitoring
Drilling
Many varieties of twist drills are available
for use. Shown is a tripod drill ensuring
90 drilling of the skull.

ICP Monitoring
Catheter Insertion
Shown is a 90 trajectory to the
scalp using a tripod. Freehand
placement can be performed
using external landmarks.

ICP Monitoring
Tunneling
Longer tunneling distances may
reduce the incidence of infection.

ICP Monitoring
CSF Drainage

Luer Hub Connector

tunneled catheter exit site
sutured incision where ventricular
catheter was passed
Dressing: provide iodine ointment (Efodine) applied daily to the
catheter exit site. Cover with gauze.
to the monitor
sampling port
3-way stopcock
15cm

drip
chamber

a) Set the level of the air vent 15 cm above ear level.

b) The drainage bag hangs below the drip chamber.
c) Drain CSF by turning the 3-way stopcock to the position shown
in the above diagram. Follow the written order for drainage.

3-way stopcock turned off to drainage system

transpac positioned at ear level

drainage bag

100cc syringe of sterile water

IMPORTANT NOTE: In order to insure an accurate reading of intracranial pressure, the

system should not be open to drainage and the monitor simultaneously. To do so means
that the transducer is averaging the actual ICP and the pressure in the drainage bag.
If a patient is open to drainage and a pressure reading must be obtained, turn the 3-way
stopcock so that it is open only to the patient and the monitor. Record the pressure,
and return the stopcock to the position that is only to the patient and the drainage bag.

ICP Monitoring
Pressure transduction
External strain gauge at
ear level

ICP Monitoring
External CSF drainage can
Be performed by a variety
of systems.

ICP Monitoring
Miniature Strain Gauge
Pressure Transduction
Can be used to monitor
parenchymal pressures.

ICP Monitoring
Fiberoptic Pressure
Transduction
Can be used to monitor
parenchymal pressures.

ICP Monitoring
Drain ventricular CSF to maintain ICP < 15mm Hg
Send CSF for protein/glucose, cell count and
culture daily
Remove the ventriculostomy if the CSF culture is
positive and place a contralateral ventriculostomy
catheter if needed
Remove ventriculostomy if ICP < 15 mm Hg without
drainage over a 24 hour period

ICP Monitoring

ICP/CPP Management
CPP = MABP - ICP
To manage intracranial hypertension
(ICP > 25mm Hg) treatment should be
aimed at decreasing ICP and maintaining
MABP 90mm Hg and CPP 70mm Hg.

ICP/CPP Management
High ICP

Cerebral Blood Flow (ml/100 g/min)

75
Passive
Collapse

Low ICP

Maximum
Dilatation

Maximum
Constriction

Zone of Normal
Autoregulation

50

Addition of vasopresors
25

0
0

25

50

75

100

Systolic Blood Pressure (mmHg)

125

150

ICP/CPP Management
TANK UP

CVP Line + Fluid Resuscitation

CVP 10 mm Hg , CPP > 70 mm Hg,
MAP > 90mm Hg

decreasing CPP, Increasing ICP

in spite of CSF drainage and euvolemia
TIGHTEN UP

agonist, Pa CO2 30-35 mm Hg

CPP >70 mm Hg, MAP > 90mm Hg
The goal is to reduce ICP, while
maintaining MAP and CPP

TBI Pharmaceutical Reference Guide

PRESSOR

HR

Dopamine*
5-20

1- 4

Dobutamine*

2-10

MABP

Norepinephrine+ 2-20
(levophed)
Phenylephrine+ 2-200
(Neo-Synephrine)
* g/kg/min

g/min

RBF

ICP/CPP Management
A three step management program based on
increasing treatment as ICP rises
Step 1: ICP < 25mm Hg
Step 2: ICP > 25mm Hg
Step 3: Herniation

Hypotension is avoided by maintaining euvolemia

and MABP 90mm Hg

ICP/CPP Management
Euvolemia CPP
(CVP 5-10) ( 70)

ICP < 25mm Hg

ICP > 25mm Hg
Herniation

+
+
+

+
+
+

CSF
PaCO2
drainage

+
+
+

35
30-35
25-30

Mannitol Paralytics MABP

Sedation (90)

+
+

Evacuate significant accessible intracranial mass lesions

Other treatments for steps 2 &3 include decompressive
craniotomy and anesthetic drugs

+
+
+

Case Presentation
Admission Assessment
30 year old
GCS 6 after resuscitation
does not open eyes to pain
does not vocalize
flexor withdrawal to pain

Pupils both equal and reactive

MABP = 90 mm Hg
Head CT
no shift
basal cisterns partially obliterated
frontal contusion

CT Scan 1
Admission CT

Case Presentation
Step I: Initial Management

Placement of ventriculostomy for ICP monitoring & treatment

CVP 5-10 mm Hg with fluid resuscitation
CPP 70 mm Hg with pressors if necessary
Evacuate extracerebral, parenchymal hematomas causing
mass effect
ICP < 20 mm Hg with CSF drainage if available
PaCO2 = 35 mm Hg by adjusting respirator rate and sedation
Sedation
see reference guide
Analgesia

Sedative Drugs
Generic Name:
Trade Name:

Midazolam
Versed

Diazepam
Valium

Lorazepam Propofol
Ativan
Diprivan

Loading dosea
Infusion ratea
Onset of action
Active metabolites
Prolonged awakening
Direct cost ($)

1-5 mg
1-20 mg/hr
Fast
Yes
Yes
High

1-10 mg
NR
Slow
Yes
Yes
Low

1-5 mg
0.5-5 mg/hr
Slow
No
Yes
Low

a Titrated to effect
NR, not recommended

0.25-0.75 g/kg
10-100 g/kg/min
Rapid
No
Infrequent
High

Case Presentation Day 2: ICU Assessment

Day 2: ICU Assessment

GCS 5
Pupils equal and reactive
MABP = 100 mm Hg
ICP = 30 mm Hg
CPP = 70 mm Hg
Head CT performed for ICP > 25mm Hg
1cm shift
basal cisterns partially obliterated
enlarged frontal hemorrhagic contusion

CT Scan 2
Day 2, Preop
Right frontal
hemorrhagic
contusion

Case Presentation
Step 2: Management of ICP > 25

Repeat CT
Evacuate Mass Lesion(s)
PaCO2 30 - 35 mm Hg
CPP 70 mm Hg, add pressors if needed
Mannitol 0.25 gm/kg bolus

CT Scan 3
Day 2, Postop
Right frontal
evacuated
contusion

Case Presentation

Evacuation of frontal hematoma

PaCO2 30 - 35 mm Hg
Receiving pressors to maintain MABP
Add short acting paralytic agent
see reference guide

Paralytics
Generic Name:

Pancuronium Vecuronium

Atracurium

Trade Name:

Pavulon

Tracrium

Loading dose (mg/kg)

Infusion described
Infusion dose (g/kg/min)
Active metabolites
Prolonged ICU block
Estimated U.S. ICU use
Direct cost ($)

0.1
Yes
1-2
Yes
Yes
15%
Low

Norcuron
0.1
Yes
1-2
Yes
Yes
60%
High

0.4-0.5
Yes
4-12
No
Rare
20%-25%
High

Case Presentation
Day 3: ICU Assessment

GCS 4
Pupils unequal, one unreactive
MABP = 110 mm Hg
ICP = 40 mm Hg
CPP = 70 mm Hg
Head CT
0.5 cm shift
basal cisterns obliterated
diffuse hemispheric swelling

CT Scan 4
Day 3,
Herniation

Case Presentation
Step 3: Herniation (Dilating Pupil)

Mannitol 0.25 gm/kg bolus

PaCO2 25 - 30 mm Hg
Consider: barbiturates or decompressive craniotomy

Neurological Exam

CT Scan 5
2 weeks after
admission

Case Presentation
Outcome Review

Ventriculostomy removal Day 7

Opens eyes to pain Day 7
Extubated Day 9
Follows simple commands Day 14
Rehabilitation for 2 months
Full neurological recovery at 6 months

ICP/CPP Management
TBI Brain is Vulnerable to Secondary Injury
Maintain Cerebral Perfusion

adequate fluid resuscitation

monitor ICP
limited hyperventilation

Develop Clinical Protocols

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