Guidelines for the Management of Severe Traumatic Brain Injury A joint initiative of: The Brain Trauma Foundation The American Association of Neurological

Guidelines for the ManagementGuidelines for the Managementof Severe Traumatic Brain Injuryof Severe Traumatic Brain Injury

A joint initiative of:A joint initiative of:

The Brain Trauma FoundationThe Brain Trauma Foundation

The American Association of Neurological SurgeonsThe American Association of Neurological Surgeons

The Joint Section on Neurotrauma and Critical CareThe Joint Section on Neurotrauma and Critical Care

TBI - EpidemiologyTBI - Epidemiology

• 60,000 ANNUAL TOTAL TBI DEATHS*60,000 ANNUAL TOTAL TBI DEATHS*• 44,000 OCCUR AT SCENE OR IN E.R.44,000 OCCUR AT SCENE OR IN E.R.• 16,000 OCCUR AFTERWARDS16,000 OCCUR AFTERWARDS

Challenge is to reduce mortalityChallenge is to reduce mortalityand improve outcome.and improve outcome.

*lower limit estimate*lower limit estimate

Sosin et al. JAMA 1995, 273:1778-1780Sosin et al. JAMA 1995, 273:1778-1780

Secondary InjurySecondary Injury

• In the past two decades, medical research has In the past two decades, medical research has demonstrated that all brain damage does not occur demonstrated that all brain damage does not occur at the moment of impact, but evolves over the at the moment of impact, but evolves over the ensuing hours and days. This is referred to as ensuing hours and days. This is referred to as secondary injury.secondary injury.

• The injured brain is extremely vulnerable to The injured brain is extremely vulnerable to hypotension, hypoxia, and increased intracranial hypotension, hypoxia, and increased intracranial pressure which are causes of secondary injury.pressure which are causes of secondary injury.

Survey of 219 hospital intensive care units in 45 states that Survey of 219 hospital intensive care units in 45 states that treated patients with severe head injury.treated patients with severe head injury.

Centers %Centers %

Routine ICP monitoring (more in high volume centers) 28Routine ICP monitoring (more in high volume centers) 28

Hyperventilation and osmotic diuretics routinely usedHyperventilation and osmotic diuretics routinely used 83 83

Aiming for PaCOAiming for PaCO22 < 25 mm Hg < 25 mm Hg 29 29

Corticosteroids use more than half the time Corticosteroids use more than half the time 64 64

Crit Care Med 23: 560-567, 1995Crit Care Med 23: 560-567, 1995

FindingsFindings

• ICP monitoring used infrequentlyICP monitoring used infrequently• Severe hyperventilationSevere hyperventilation• Use of steroids currently not indicatedUse of steroids currently not indicated• Wide variability in practiceWide variability in practice

Significant Reductions in MortalitySignificant Reductions in Mortalityand Morbidityand Morbidity

• Rapid transport to a trauma care facilityRapid transport to a trauma care facility• Prompt resuscitationPrompt resuscitation• CT scanningCT scanning• Prompt evacuation of significant intracranial Prompt evacuation of significant intracranial

hematomashematomas• ICP monitoring and treatmentICP monitoring and treatment

GuideGuidelines for Management of Severe TBIlines for Management of Severe TBI

Objectives:Objectives:• STATE and DISSEMINATE the current scientificSTATE and DISSEMINATE the current scientific

evidence for the OPTIMAL management of TBI.evidence for the OPTIMAL management of TBI.• Highlight issues for further RESEARCH andHighlight issues for further RESEARCH and

CLINICAL TRIALS.CLINICAL TRIALS.• Improve OUTCOME.Improve OUTCOME.


AuthorsAuthors

Ross BullockRoss Bullock Raj NarayanRaj Narayan

Randall ChesnutRandall Chesnut David NewellDavid Newell

Guy CliftonGuy Clifton Lawrence PittsLawrence Pitts

Jamshid GhajarJamshid Ghajar Michael RosnerMichael Rosner

Donald MarionDonald Marion Beverly WaltersBeverly Walters

Jack WilbergerJack Wilberger

HistoryHistory

• 11 authors and 14 topics11 authors and 14 topics• 3 years of meetings3 years of meetings• Over 3000 articles reviewedOver 3000 articles reviewed• 1st edition completed in 19951st edition completed in 1995• 2nd edition completed in 19992nd edition completed in 1999

Funded and supported by theBrain Trauma Foundation (BTF)

Advisory CommitteeAdvisory Committee

• Mark Dearden, M.D.Mark Dearden, M.D.• Robert Florin, M.D.Robert Florin, M.D.• Andrew Jagoda, M.D.Andrew Jagoda, M.D.• James P. Kelly, M.D.James P. Kelly, M.D.• Andrew Maas, M.D.Andrew Maas, M.D.• Anthony Marmarou, Ph.D.Anthony Marmarou, Ph.D.• J. Douglas Miller, M.D.J. Douglas Miller, M.D.

Advisory CommitteeAdvisory Committee

• Peter C. QuinnPeter C. Quinn• Jay Rosenberg, M.D.Jay Rosenberg, M.D.• Franco Servadei, M.D.Franco Servadei, M.D.• Nino Stocchetti, M.D.Nino Stocchetti, M.D.• Graham Teasdale, M.D.Graham Teasdale, M.D.• Andreas Unterberg, M.D.Andreas Unterberg, M.D.• Hans von Holst, M.D.Hans von Holst, M.D.• Alex Valadka, M.D.Alex Valadka, M.D.

Topics Topics

• Trauma SystemsTrauma Systems• Initial ManagementInitial Management• Resuscitation of Blood Pressure and OxygenationResuscitation of Blood Pressure and Oxygenation• Indications for ICP MonitoringIndications for ICP Monitoring• ICP Treatment ThresholdICP Treatment Threshold• ICP Monitoring TechnologyICP Monitoring Technology• Cerebral Perfusion PressureCerebral Perfusion Pressure

TopicsTopics

• HyperventilationHyperventilation• MannitolMannitol• BarbituratesBarbiturates• SteroidsSteroids• ICP Treatment AlgorithmICP Treatment Algorithm• NutritionNutrition• Antiseizure ProphalyxisAntiseizure Prophalyxis

Topic Chapter FormatTopic Chapter Format

I.I. RecommendationsRecommendationsA.A. StandardsStandards

B.B. GuidelinesGuidelines

C.C. OptionsOptions

II.II. OverviewOverview

III.III. ProcessProcess

IV.IV. Scientific FoundationScientific Foundation

V.V. SummarySummary

VI.VI. Key Issues for Future InvestigationKey Issues for Future Investigation

VII.VII. Evidentiary TableEvidentiary Table

VIII.VIII. ReferencesReferences


Topics listTopics list• Electronic literature search (Medline)Electronic literature search (Medline)• All relevant articles:All relevant articles:

– Screened for scientific and statistical validityScreened for scientific and statistical validity– Classified according to a three point scaleClassified according to a three point scale

• Class IClass I• Class IIClass II• Class IIIClass III


Class IClass I• Prospective, Randomized, Controlled TrialsProspective, Randomized, Controlled Trials

Class IIClass II• Non-Randomized, Prospective Controlled TrialsNon-Randomized, Prospective Controlled Trials• Observational StudiesObservational Studies

Class IIIClass III• Case SeriesCase Series• Case ReportsCase Reports• Expert OpinionExpert Opinion


StandardsStandards• Class I EvidenceClass I Evidence

GuidelinesGuidelines• Class II EvidenceClass II Evidence

OptionsOptions• Class III EvidenceClass III Evidence


StandardsStandards• Represent principles that reflect a Represent principles that reflect a highhigh degree degree

of clinical certaintyof clinical certainty

GuidelinesGuidelines• Represent principles that reflect a Represent principles that reflect a moderatemoderate degree degree

of clinical certaintyof clinical certainty

OptionsOptions• Represent principles for which there is Represent principles for which there is unclearunclear

clinical certaintyclinical certainty


““The Spirit is Willing but the Data is Weak”The Spirit is Willing but the Data is Weak”• State only what the literature supportsState only what the literature supports

– First step toward standardizing head injury managementFirst step toward standardizing head injury management– Mandate for Class I studiesMandate for Class I studies

Trauma SystemsTrauma Systems

GuidelineGuideline• All regions in the United States should have an All regions in the United States should have an

organized trauma care systemorganized trauma care system

• 1643 trauma patients treated at seven trauma 1643 trauma patients treated at seven trauma centers with differing annual volumes of trauma centers with differing annual volumes of trauma patients.patients.

• Patients taken to a low volume trauma center hadPatients taken to a low volume trauma center hada 30% greater chance of dying.a 30% greater chance of dying.

J. Trauma 30: 1066-1076, 1990J. Trauma 30: 1066-1076, 1990

Resuscitation of Blood PressureResuscitation of Blood Pressure& Oxygenation& Oxygenation

GuidelineGuideline• Hypotension (SBP < 90 mm Hg) or hypoxiaHypotension (SBP < 90 mm Hg) or hypoxia

(apnea of cyanosis in the field or a PaO(apnea of cyanosis in the field or a PaO22 < 60 mm < 60 mm

Hg)Hg)must be scrupulously avoided, if possible, ormust be scrupulously avoided, if possible, orcorrected immediately.corrected immediately.

OptionOption• The mean arterial pressure should be maintainedThe mean arterial pressure should be maintained

above 90 mm Hg throughout the patient’s course.above 90 mm Hg throughout the patient’s course.

• Prospective prehospital and E.R. study of 717 Prospective prehospital and E.R. study of 717 severe head injury patients in the Traumatic Coma severe head injury patients in the Traumatic Coma Data Bank.Data Bank.

• Hypotension (SBP < 90 mm Hg) occurred in 35%Hypotension (SBP < 90 mm Hg) occurred in 35%of patients and was associated with a two fold of patients and was associated with a two fold increase in mortality.increase in mortality.

J. Trauma 34:216-222, 1993J. Trauma 34:216-222, 1993

Initial ManagementInitial Management

OptionOption• The first priority for the head injured patient is The first priority for the head injured patient is

complete and rapid physiologic resuscitation.complete and rapid physiologic resuscitation.No specific treatment should be directed at No specific treatment should be directed at intracranial hypertension in the absence of signsintracranial hypertension in the absence of signsof transtentorial herniation or progressiveof transtentorial herniation or progressiveneurologic deterioration not attributable to neurologic deterioration not attributable to extracranial explanations.extracranial explanations.

• CBF measured in 35 severely head injured patients CBF measured in 35 severely head injured patients with Xe-CT at, on average, 3 hours after injury.with Xe-CT at, on average, 3 hours after injury.

• Global or regional ischemia (CBF < 18 ml/100 Global or regional ischemia (CBF < 18 ml/100 gm/min) observed in 31% patients.gm/min) observed in 31% patients.

• Global ischemia was measured in 57% of patients Global ischemia was measured in 57% of patients with diffuse swelling.with diffuse swelling.

J. Neurosurg 77: 360-368, 1992J. Neurosurg 77: 360-368, 1992

Indications for ICP MonitoringIndications for ICP Monitoring

GuidelineGuideline• ICP monitoring is appropriate in severe head injury ICP monitoring is appropriate in severe head injury

patients with an abnormal CT, or a normal CT scan patients with an abnormal CT, or a normal CT scan if 2 or more of the following are noted on admission:if 2 or more of the following are noted on admission:

– SBP < 90 mm HgSBP < 90 mm Hg– Age > 40 yearsAge > 40 years– Uni-/Bilateral motor posturingUni-/Bilateral motor posturing

• 207 severely head injured patients who had ICP monitoring 207 severely head injured patients who had ICP monitoring and head CT scansand head CT scans

• Patients with a normal head CT had a 13% chance of ICP > Patients with a normal head CT had a 13% chance of ICP > 20 mm Hg20 mm Hg

• Risk of intracranial hypertension (with normal CT) increased Risk of intracranial hypertension (with normal CT) increased to 60% if two or more of the following were noted:to 60% if two or more of the following were noted:

– 1) Age over 40 years1) Age over 40 years– 2) SBP < 90 mm Hg2) SBP < 90 mm Hg– 3) motor posturing3) motor posturing


ICP Monitoring TechnologyICP Monitoring Technology

RecommendationRecommendation• In the current state of technology, the ventricular In the current state of technology, the ventricular

catheter connected to an external strain gauge iscatheter connected to an external strain gauge isthe most accurate, low cost, and reliable methodthe most accurate, low cost, and reliable methodof monitoring ICP. It also allows therapeuticof monitoring ICP. It also allows therapeuticCSF drainage. CSF drainage.

• ICP transduction via fiberoptic or strain gauge ICP transduction via fiberoptic or strain gauge devices placed in ventricular catheters provide devices placed in ventricular catheters provide similar benefits but at a higher cost.similar benefits but at a higher cost.

CT ScanCT Scan

ICP Treatment ThresholdICP Treatment Threshold

GuidelineGuideline• ICP treatment should be initiated at an upper ICP treatment should be initiated at an upper

threshold of 20 - 25 mm Hg.threshold of 20 - 25 mm Hg.

• The ICP threshold that was most predictive of 6 month The ICP threshold that was most predictive of 6 month outcome was analyzed in 428 severely head injured patients.outcome was analyzed in 428 severely head injured patients.

• The proportion of hourly ICP reading greater than 20 mm Hg The proportion of hourly ICP reading greater than 20 mm Hg was a significant independent determinant of outcome.was a significant independent determinant of outcome.

J. Neurosurg 75:S59-S66, 1991J. Neurosurg 75:S59-S66, 1991

Cerebral Perfusion PressureCerebral Perfusion Pressure

OptionOption• Cerebral Perfusion Pressure should beCerebral Perfusion Pressure should be

maintained at a minimum of 70 mm Hg.maintained at a minimum of 70 mm Hg.

• 158 patients with GCS < 7 managed according to a158 patients with GCS < 7 managed according to aCPP protocol:CPP protocol:

– Maintain euvolemia (CVP 8-10 mm Hg)Maintain euvolemia (CVP 8-10 mm Hg)

– Ventriculostomy CSF drainage at 15 mm HgVentriculostomy CSF drainage at 15 mm Hg

– Systemic vasopressors to maintain CPP at least 70 mm HgSystemic vasopressors to maintain CPP at least 70 mm Hg

– Hyperventilation, barbiturates, hypothermia not used.Hyperventilation, barbiturates, hypothermia not used.

• Mortality 29% and 2% vegetative for entire group. Favorable Mortality 29% and 2% vegetative for entire group. Favorable outcome in GCS 3 of 35% ranging up to 75% for GCS 7.outcome in GCS 3 of 35% ranging up to 75% for GCS 7.


HyperventilationHyperventilation

StandardStandard • In the absence of increased intracranial pressure (ICP), chronic In the absence of increased intracranial pressure (ICP), chronic

prolonged hyperventilation therapy (PaCOprolonged hyperventilation therapy (PaCO22 of 25 mm Hg or less) of 25 mm Hg or less)should be avoided after severe traumatic brain injury (TBI).should be avoided after severe traumatic brain injury (TBI).

GuidelineGuideline• The use of prophylactic hyperventilation (PaCOThe use of prophylactic hyperventilation (PaCO22 < 35 mm Hg) < 35 mm Hg)

therapy during the first 24 hours after severe TBI should be avoided therapy during the first 24 hours after severe TBI should be avoided because it can compromise cerebral perfusion during a time when because it can compromise cerebral perfusion during a time when cerebral blood flow (CBF) is reduced.cerebral blood flow (CBF) is reduced.

OptionOption• Hyperventilation therapy may be necessary for brief periods when Hyperventilation therapy may be necessary for brief periods when

there is acute neurologic deterioration, or for longer periods if there is there is acute neurologic deterioration, or for longer periods if there is intracranial hypertension refractory to sedation, paralysis, intracranial hypertension refractory to sedation, paralysis, cerebrospinal fluid (CSF) drainage, and osmotic diuretics.cerebrospinal fluid (CSF) drainage, and osmotic diuretics.

J. Neurosurg 75:731-739, 1991J. Neurosurg 75:731-739, 1991

• A randomized prospective clinical trial in 113 patients to A randomized prospective clinical trial in 113 patients to study the effect of hyperventilation (PaCostudy the effect of hyperventilation (PaCo22 25 mm Hg) 25 mm Hg)

compared to normal ventilation (PaCocompared to normal ventilation (PaCo22 35 mm Hg) in 35 mm Hg) in

patients with similar severe head injury.patients with similar severe head injury.

• Significantly fewer patients made a good recovery atSignificantly fewer patients made a good recovery at3 and 6 months post injury who had a GCS 6 or 73 and 6 months post injury who had a GCS 6 or 7on admission.on admission.

““PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION FOR A PERIOD PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION FOR A PERIOD OF 5 DAYS RETARDS RECOVERY FROM SEVERE HEAD INJURY.” OF 5 DAYS RETARDS RECOVERY FROM SEVERE HEAD INJURY.”

MannitolMannitol

GuidelineGuideline• Mannitol is effective for control of raised ICP after Mannitol is effective for control of raised ICP after

severe head injury.severe head injury.

OptionOption• Effective doses range from 0.25 - 1.0 gm/kgEffective doses range from 0.25 - 1.0 gm/kg

body weight.body weight.

MannitolMannitol

OptionOption• The indications for the use of mannitol prior to ICP The indications for the use of mannitol prior to ICP

monitoring are signs of transtentorial herniation or monitoring are signs of transtentorial herniation or progressive neurological deterioration not progressive neurological deterioration not attributable to systemic pathology. attributable to systemic pathology.

• However, hypovolemia should be avoided byHowever, hypovolemia should be avoided byfluid replacement.fluid replacement.

BarbituratesBarbiturates

GuidelineGuideline• High-dose barbiturate therapy may be consideredHigh-dose barbiturate therapy may be considered

in hemodynamically stable salvagable severe head in hemodynamically stable salvagable severe head injury patients with intracranial hypertension injury patients with intracranial hypertension refractory to maximal medical and surgical ICP refractory to maximal medical and surgical ICP lowering therapy.lowering therapy.

• A prospective trial of 73 patients with severe head injury and A prospective trial of 73 patients with severe head injury and medically refractory intracranial hypertension, randomized to medically refractory intracranial hypertension, randomized to receive either a regimen including high-dose pentobarbital or receive either a regimen including high-dose pentobarbital or similar regiment without pentobarbital.similar regiment without pentobarbital.

• Refractory intracranial hypertension occurred in only 12%Refractory intracranial hypertension occurred in only 12%of the original severe head injury group (925 Patients).of the original severe head injury group (925 Patients).

• The chance of survival for those patients whose ICP The chance of survival for those patients whose ICP decreased(ICP < 20 mm Hg) with barbiturate treatmentdecreased(ICP < 20 mm Hg) with barbiturate treatmentwas 92% compared to 17% when it did not.was 92% compared to 17% when it did not.


SteroidsSteroids

StandardStandard• The use of steroids is not recommended for The use of steroids is not recommended for

improving outcome or reducing intracranial pressure improving outcome or reducing intracranial pressure in patients with severe head injury.in patients with severe head injury.

• Prospective randomized trial in 300 patients Prospective randomized trial in 300 patients receiving dexamethasone (total IV dose withinreceiving dexamethasone (total IV dose within51 hours of injury = 2.3 grams IV) versus placebo.51 hours of injury = 2.3 grams IV) versus placebo.

• No difference in outcome examined serially within No difference in outcome examined serially within one year after treatment.one year after treatment.

Zentralbl Neurochir 55:135-143, 1994Zentralbl Neurochir 55:135-143, 1994

Antiseizure ProphylaxisAntiseizure Prophylaxis

StandardStandard• Prophylactic use of phenytoin, carbamazepine, Prophylactic use of phenytoin, carbamazepine,

phenobarbital or valproate is not recommendedphenobarbital or valproate is not recommendedfor preventing for preventing latelate post-traumatic seizures. post-traumatic seizures.

• 404 post traumatic head injury patients (GCS 3-10 and 404 post traumatic head injury patients (GCS 3-10 and abnormal head CT) randomized to treatment with phenytoin abnormal head CT) randomized to treatment with phenytoin or placebo for one year with a two year follow up.or placebo for one year with a two year follow up.

• In the first week after injury 4% of the patients receiving In the first week after injury 4% of the patients receiving phenytoin had seizures compared to 14% taking placebo.phenytoin had seizures compared to 14% taking placebo.

• After the first week there was no significant difference After the first week there was no significant difference between the rate of seizures in the two groups. between the rate of seizures in the two groups.

N. Engl. J. Med 323:497-502, 1990N. Engl. J. Med 323:497-502, 1990

NutritionNutrition

GuidelineGuideline• Replacement of 140% of Resting Metabolic Replacement of 140% of Resting Metabolic

Expenditure in non-paralyzed patients and Expenditure in non-paralyzed patients and 100% Resting Metabolic Expenditure in100% Resting Metabolic Expenditure inparalyzed patients using enteral or parenteral paralyzed patients using enteral or parenteral formulas containing at least 15% of calories as formulas containing at least 15% of calories as protein by the seventh day after injury.protein by the seventh day after injury.

• Prospective trial in 38 patients randomly assigned to Prospective trial in 38 patients randomly assigned to receive total parenteral nutrition (TPN) or standard receive total parenteral nutrition (TPN) or standard enteral nutrition (SEN).enteral nutrition (SEN).

• The TPN group got full nutritional support by 7 days The TPN group got full nutritional support by 7 days whereas the SEN group did not. There were significantly whereas the SEN group did not. There were significantly more deaths in the group that did not receive full caloric more deaths in the group that did not receive full caloric replacement by the 7th day after injury.replacement by the 7th day after injury.


ICP Treatment AlgorithmICP Treatment Algorithm

OptionOption• An algorithm, developed by consensus, is An algorithm, developed by consensus, is

presented. It should be viewed as “expert opinion” presented. It should be viewed as “expert opinion” and used as a framework which may be useful in and used as a framework which may be useful in guiding an approach to treating intracranial guiding an approach to treating intracranial hypertension.hypertension.

Critical Pathway for Treatment of Intracranial Critical Pathway for Treatment of Intracranial Hypertension in the Severe Head Injury Patient Hypertension in the Severe Head Injury Patient (Treatment Option)(Treatment Option)

*Threshold of 20-25 mmHg may be used. Other values may be substituted in individual conditions.

May Repeat Mannitolif Serum Osmolarity

< 320 mOsm/L &Pt euvolemic

High DoseBarbiturate therapy

High DoseBarbiturate therapy

• Hyperventilation to PaCO2 < 30 mmHg• Monitoring SjO2, AVDO2, and/orCBF

Recommended

Other SecondTier Therapies

NO

YES NO

YES NO

YES NO

CarefullyWithdraw

ICP Treatment

ConsiderRepeatingCT Scan

YES

Second Tier Therapy

Intracranial Hypertension?

Hyperventilation to PaCO2 30 - 35 mmHg


Mannitol (0.25 - 1.0 g/kg IV)


Ventricular Drainage (if available)

Intracranial Hypertension?*

Maintain CPP 70 mmHg

Insert ICP Monitor

Guidelines for the Management of Guidelines for the Management of

Severe Traumatic Brain InjurySevere Traumatic Brain InjuryTo place an order call:To place an order call:

Brain Trauma FoundationBrain Trauma Foundation@ 1-212-772-0608@ 1-212-772-0608fax 1-212-772-0357fax 1-212-772-0357

www. braintrauma.orgwww. braintrauma.org

Documents

Guidelines for the Management of Severe Traumatic Brain Injury A joint initiative of: The Brain Trauma Foundation The American Association of Neurological