What are the specific doctor's orders for a patient with a traumatic brain injury (TBI) to be written on the chart?

From the Guidelines

For traumatic brain injury patients, doctors should prioritize writing orders for airway control through tracheal intubation, mechanical ventilation, and end-tidal CO2 monitoring to maintain optimal cerebral circulation and prevent secondary brain insults. This approach is supported by the strongest evidence, which emphasizes the importance of controlling ventilation in severe traumatic brain injury patients throughout the pre-hospital period and during hospital stay 1.

Key orders to be written on the chart include:

• Tracheal intubation and mechanical ventilation to control PaCO2 levels and prevent hypocapnia-induced cerebral vasoconstriction
• End-tidal CO2 monitoring to ensure correct placement of the tracheal tube and maintain PaCO2 within a target range
• External ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults, as suggested by recent guidelines 1
• Neurological assessments every 1-2 hours, including Glasgow Coma Scale, pupil checks, and motor function, to closely monitor the patient's condition
• Vital sign monitoring with parameters for notification, such as systolic BP >160 or <90 mmHg, heart rate >120 or <50 bpm, and oxygen saturation <95%

Additionally, medication orders may include:

• Analgesics, such as acetaminophen, to manage pain while avoiding NSAIDs
• Anticonvulsants, like levetiracetam, if indicated to prevent seizures
• Osmotic therapy, including mannitol or hypertonic saline, to manage increased intracranial pressure

It is also crucial to specify orders for diet status, DVT prophylaxis, and rehabilitation consultation to prevent complications and promote optimal recovery outcomes. By prioritizing these orders, healthcare providers can help prevent secondary brain injury, maintain adequate cerebral perfusion, and improve neurological outcomes for traumatic brain injury patients.

From the FDA Drug Label

1. 2 Recommended Dosage Reduction of Intracranial Pressure and Brain Mass In adults a dose of 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes; pediatric patients 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes.

The doctor's order for traumatic brain injury should be written on the chart as:

• Mannitol
• Dose: 0.25 to 2 g/kg body weight
• Concentration: 15% to 25% solution
• Administration rate: over a period of 30 to 60 minutes
• Monitoring: careful evaluation of circulatory and renal reserve, fluid and electrolyte balance, body weight, and total input and output before and after infusion of mannitol 2

From the Research

Traumatic Brain Injury Management

When managing traumatic brain injury, specific doctor's orders should be written on the chart to ensure proper care. Some of these orders may include:

• Maintaining optimal cerebral perfusion pressure (CPP) through mean arterial pressure (MAP) optimization and intracranial pressure (ICP) management 3
• Utilizing hyperosmolar therapy, such as mannitol or hypertonic saline, to reduce ICP 4, 5, 6, 7
• Implementing bedside maneuvers, sedation, and cerebrospinal fluid (CSF) drainage to decrease ICP 3
• Considering direct ICP monitoring and brain tissue oxygen (PbtO2) monitoring to guide therapy 3
• Providing early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization 3

Medication Orders

Medication orders for traumatic brain injury may include:

• Mannitol, which may have a beneficial effect on mortality when compared to pentobarbital treatment, but may have a detrimental effect on mortality when compared to hypertonic saline 4, 5, 6
• Hypertonic saline, which may be used as an alternative to mannitol for ICP management 7
• Vasopressors, which may be used to optimize mean arterial pressure (MAP) and maintain cerebral perfusion pressure (CPP) 3

Monitoring and Assessment

Monitoring and assessment orders for traumatic brain injury may include:

• Regular assessment of neurological signs and physiological indicators, such as Glasgow Coma Scale (GCS) and ICP monitoring 3
• Imaging studies, such as CT or MRI scans, to evaluate the extent of brain injury and guide therapy 3
• Brain tissue oxygen (PbtO2) monitoring to optimize cerebral blood flow (CBF) 3