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

TBI - Epidemiology

60,000 ANNUAL TOTAL TBI DEATHS*

44,000 OCCUR AT SCENE OR IN E.R.
16,000 OCCUR AFTERWARDS
Challenge is to reduce mortality
and improve outcome.

*lower limit estimate

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

Secondary Injury
In the past two decades, medical research has
demonstrated that all brain damage does not occur
at the moment of impact, but evolves over the
ensuing hours and days. This is referred to as
secondary injury.
The injured brain is extremely vulnerable to
hypotension, hypoxia, and increased intracranial
pressure which are causes of secondary injury.

Survey of 219 hospital intensive care units in 45 states that

treated patients with severe head injury.
Centers %
Routine ICP monitoring (more in high volume centers) 28
Hyperventilation and osmotic diuretics routinely used
83
Aiming for PaCO2 < 25 mm Hg
29
Corticosteroids use more than half the time
64

Crit Care Med 23: 560-567, 1995

Findings

ICP monitoring used infrequently

Severe hyperventilation
Use of steroids currently not indicated
Wide variability in practice

Significant Reductions in Mortality

and Morbidity

Rapid transport to a trauma care facility

Prompt resuscitation
CT scanning
Prompt evacuation of significant intracranial
hematomas
ICP monitoring and treatment

Guidelines for Management of Severe TBI

Objectives:
STATE and DISSEMINATE the current scientific
evidence for the OPTIMAL management of TBI.
Highlight issues for further RESEARCH and
CLINICAL TRIALS.
Improve OUTCOME.

Guidelines for the Management

of Severe Traumatic Brain Injury
Authors
Ross Bullock
Randall Chesnut
Guy Clifton
Jamshid Ghajar
Donald Marion
Jack Wilberger

Raj Narayan
David Newell
Lawrence Pitts
Michael Rosner
Beverly Walters

History

11 authors and 14 topics

3 years of meetings
Over 3000 articles reviewed
1st edition completed in 1995
2nd edition completed in 1999

Funded and supported by the

Brain Trauma Foundation (BTF)

Advisory Committee

Mark Dearden, M.D.

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

Advisory Committee

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

Topics

Trauma Systems
Initial Management
Resuscitation of Blood Pressure and Oxygenation
Indications for ICP Monitoring
ICP Treatment Threshold
ICP Monitoring Technology
Cerebral Perfusion Pressure

Topics

Hyperventilation
Mannitol
Barbiturates
Steroids
ICP Treatment Algorithm
Nutrition
Antiseizure Prophalyxis

Topic Chapter Format

I. Recommendations
A. Standards
B. Guidelines
C. Options

II. Overview
III. Process
IV. Scientific Foundation
V. Summary
VI. Key Issues for Future Investigation
VII. Evidentiary Table
VIII. References

Guidelines for the Management

of Severe Traumatic Brain Injury
Topics list
Electronic literature search (Medline)
All relevant articles:
Screened for scientific and statistical validity
Classified according to a three point scale
Class I
Class II
Class III

Guidelines for the Management

of Severe Traumatic Brain Injury
Class I
Prospective, Randomized, Controlled Trials
Class II
Non-Randomized, Prospective Controlled Trials
Observational Studies
Class III
Case Series
Case Reports
Expert Opinion

Guidelines for the Management

of Severe Traumatic Brain Injury
Standards
Class I Evidence
Guidelines
Class II Evidence
Options
Class III Evidence

Guidelines for the Management

of Severe Traumatic Brain Injury
Standards
Represent principles that reflect a high degree
of clinical certainty
Guidelines
Represent principles that reflect a moderate degree
of clinical certainty
Options
Represent principles for which there is unclear
clinical certainty

Guidelines for the Management

of Severe Traumatic Brain Injury
The Spirit is Willing but the Data is Weak
State only what the literature supports
First step toward standardizing head injury management
Mandate for Class I studies

Trauma Systems
Guideline
All regions in the United States should have an
organized trauma care system

 1643 trauma patients treated at seven trauma

centers with differing annual volumes of trauma
patients.
Patients taken to a low volume trauma center had
a 30% greater chance of dying.

J. Trauma 30: 1066-1076, 1990

Resuscitation of Blood Pressure

& Oxygenation
Guideline
Hypotension (SBP < 90 mm Hg) or hypoxia
(apnea of cyanosis in the field or a PaO2 < 60 mm
Hg)
must be scrupulously avoided, if possible, or
corrected immediately.
Option
The mean arterial pressure should be maintained
above 90 mm Hg throughout the patients course.

 Prospective prehospital and E.R. study of 717

severe head injury patients in the Traumatic Coma
Data Bank.
Hypotension (SBP < 90 mm Hg) occurred in 35%
of patients and was associated with a two fold
increase in mortality.

J. Trauma 34:216-222, 1993

Initial Management
Option
The first priority for the head injured patient is
complete and rapid physiologic resuscitation.
No specific treatment should be directed at
intracranial hypertension in the absence of signs
of transtentorial herniation or progressive
neurologic deterioration not attributable to
extracranial explanations.

 CBF measured in 35 severely head injured patients

with Xe-CT at, on average, 3 hours after injury.
Global or regional ischemia (CBF < 18 ml/100
gm/min) observed in 31% patients.
Global ischemia was measured in 57% of patients
with diffuse swelling.
J. Neurosurg 77: 360-368, 1992

Indications for ICP Monitoring

Guideline
ICP monitoring is appropriate in severe head injury
patients with an abnormal CT, or a normal CT scan if
2 or more of the following are noted on admission:
SBP < 90 mm Hg
Age > 40 years
Uni-/Bilateral motor posturing

 207 severely head injured patients who had ICP monitoring

and head CT scans
Patients with a normal head CT had a 13% chance of ICP >
20 mm Hg
Risk of intracranial hypertension (with normal CT) increased
to 60% if two or more of the following were noted:

1) Age over 40 years

2) SBP < 90 mm Hg
3) motor posturing

J. Neurosurg 56: 650-659, 1982

ICP Monitoring Technology

Recommendation
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 ICP. It also allows therapeutic
CSF drainage.
ICP transduction via fiberoptic or strain gauge
devices placed in ventricular catheters provide
similar benefits but at a higher cost.

CT Scan

ICP Treatment Threshold

Guideline
ICP treatment should be initiated at an upper
threshold of 20 - 25 mm Hg.

 The ICP threshold that was most predictive of 6 month

outcome was analyzed in 428 severely head injured patients.
The proportion of hourly ICP reading greater than 20 mm Hg
was a significant independent determinant of outcome.
J. Neurosurg 75:S59-S66, 1991

Cerebral Perfusion Pressure

Option
Cerebral Perfusion Pressure should be
maintained at a minimum of 70 mm Hg.

 158 patients with GCS < 7 managed according to a

CPP protocol:
Maintain euvolemia (CVP 8-10 mm Hg)
Ventriculostomy CSF drainage at 15 mm Hg
Systemic vasopressors to maintain CPP at least 70 mm Hg
Hyperventilation, barbiturates, hypothermia not used.

Mortality 29% and 2% vegetative for entire group. Favorable

outcome in GCS 3 of 35% ranging up to 75% for GCS 7.
J. Neurosurg 83: 949-962, 1992

Hyperventilation
Standard
In the absence of increased intracranial pressure (ICP), chronic
prolonged hyperventilation therapy (PaCO 2 of 25 mm Hg or less)
should be avoided after severe traumatic brain injury (TBI).

Guideline
The use of prophylactic hyperventilation (PaCO 2 < 35 mm Hg) therapy
during the first 24 hours after severe TBI should be avoided because it
can compromise cerebral perfusion during a time when cerebral blood
flow (CBF) is reduced.

Option
Hyperventilation therapy may be necessary for brief periods when there
is acute neurologic deterioration, or for longer periods if there is
intracranial hypertension refractory to sedation, paralysis, cerebrospinal
fluid (CSF) drainage, and osmotic diuretics.

 A randomized prospective clinical trial in 113 patients to

study the effect of hyperventilation (PaCo2 25 mm Hg)
compared to normal ventilation (PaCo2 35 mm Hg) in
patients with similar severe head injury.
Significantly fewer patients made a good recovery at
3 and 6 months post injury who had a GCS 6 or 7
on admission.
PROPHYLACTIC USE OF SUSTAINED HYPERVENTILATION FOR A PERIOD
OF 5 DAYS RETARDS RECOVERY FROM SEVERE HEAD INJURY.
J. Neurosurg 75:731-739, 1991

Mannitol
Guideline
Mannitol is effective for control of raised ICP after
severe head injury.
Option
Effective doses range from 0.25 - 1.0 gm/kg
body weight.

Mannitol
Option
The indications for the use of mannitol prior to ICP
monitoring are signs of transtentorial herniation or
progressive neurological deterioration not
attributable to systemic pathology.
However, hypovolemia should be avoided by
fluid replacement.

Barbiturates
Guideline
High-dose barbiturate therapy may be considered
in hemodynamically stable salvagable severe head
injury patients with intracranial hypertension
refractory to maximal medical and surgical ICP
lowering therapy.

 A prospective trial of 73 patients with severe head injury and

medically refractory intracranial hypertension, randomized to
receive either a regimen including high-dose pentobarbital or
similar regiment without pentobarbital.
Refractory intracranial hypertension occurred in only 12%
of the original severe head injury group (925 Patients).
The chance of survival for those patients whose ICP
decreased(ICP < 20 mm Hg) with barbiturate treatment
was 92% compared to 17% when it did not.
J. Neurosurg 69:15-23, 1988

Steroids
Standard
The use of steroids is not recommended for
improving outcome or reducing intracranial pressure
in patients with severe head injury.

 Prospective randomized trial in 300 patients

receiving dexamethasone (total IV dose within
51 hours of injury = 2.3 grams IV) versus placebo.
No difference in outcome examined serially within
one year after treatment.
Zentralbl Neurochir 55:135-143, 1994

Antiseizure Prophylaxis
Standard
Prophylactic use of phenytoin, carbamazepine,
phenobarbital or valproate is not recommended
for preventing late post-traumatic seizures.

 404 post traumatic head injury patients (GCS 3-10 and

abnormal head CT) randomized to treatment with phenytoin
or placebo for one year with a two year follow up.
In the first week after injury 4% of the patients receiving
phenytoin had seizures compared to 14% taking placebo.
After the first week there was no significant difference
between the rate of seizures in the two groups.
N. Engl. J. Med 323:497-502, 1990

Nutrition
Guideline
Replacement of 140% of Resting Metabolic
Expenditure in non-paralyzed patients and
100% Resting Metabolic Expenditure in
paralyzed patients using enteral or parenteral
formulas containing at least 15% of calories as
protein by the seventh day after injury.

 Prospective trial in 38 patients randomly assigned to

receive total parenteral nutrition (TPN) or standard
enteral nutrition (SEN).
The TPN group got full nutritional support by 7 days
whereas the SEN group did not. There were significantly
more deaths in the group that did not receive full caloric
replacement by the 7th day after injury.
J. Neurosurg 58:907-912, 1983

ICP Treatment Algorithm

Option
An algorithm, developed by consensus, is
presented. It should be viewed as expert opinion
and used as a framework which may be useful in
guiding an approach to treating intracranial
hypertension.

Critical Pathway for Treatment of Intracranial

Hypertension in the Severe Head Injury Patient
(Treatment Option)
Insert ICP Monitor
Maintain CPP 70 mmHg
YES

NO

Intracranial Hypertension?*
Ventricular Drainage (if available)

YES
Consider
Repeating
CT Scan

Intracranial Hypertension?

NO

Mannitol (0.25 - 1.0 g/kg IV)

YES

Intracranial Hypertension?

NO

May Repeat Mannitol

if Serum Osmolarity
< 320 mOsm/L &
Pt euvolemic

Carefully
Withdraw
ICP Treatment

Hyperventilation to PaCO2 30 - 35 mmHg

YES
Other Second
Tier Therapies

Intracranial Hypertension?

High Dose
Barbiturate therapy

NO
Hyperventilation to PaCO2 < 30 mmHg
Monitoring SjO2, AVDO2, and/orCBF
Recommended
Second Tier Therapy

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

Guidelines for the Management of

Severe Traumatic
Brain
Injury
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