From the Guidelines
For traumatic brain injury (TBI) patients, specific doctor's orders on the chart should include maintaining a systolic blood pressure > 110 mmHg, as recommended by the most recent and highest quality study 1. This is crucial in preventing secondary brain injury and improving neurological outcomes. The orders should also specify:
- Neurological assessments every 1-2 hours using the Glasgow Coma Scale, pupil checks, and vital sign monitoring with parameters for notification (systolic BP <90 or >160 mmHg, heart rate <50 or >120 bpm, oxygen saturation <95%) 1.
- Head elevation at 30 degrees to reduce intracranial pressure.
- Seizure prophylaxis with Levetiracetam 500-1000 mg IV twice daily for 7 days in moderate to severe TBI.
- Pain control with acetaminophen 1000 mg every 6 hours and avoiding NSAIDs.
- DVT prophylaxis with sequential compression devices initially, transitioning to enoxaparin 40 mg subcutaneously daily when stable.
- Fluid management with isotonic solutions (normal saline or Lactated Ringer's), avoiding hypotonic fluids which can worsen cerebral edema.
- Temperature management targeting normothermia (36.5-37.5°C), with acetaminophen for temperatures >38°C, as recommended by the latest guidelines 1. These measures help prevent secondary brain injury by maintaining adequate cerebral blood flow, controlling intracranial pressure, preventing seizures, and avoiding complications that could worsen neurological outcomes. Key considerations include:
- Performing a brain and cervical computed tomography (CT) scan without delay in severe traumatic brain injury patients, as recommended by 1.
- Maintaining cerebral perfusion pressure >60 mmHg and intracranial pressure <22 mmHg if monitored.
- Avoiding hypotensive hypnotic agents, continuous sedation rather than bolus of sedatives, correction of hypovolaemia if needed, and mechanical ventilation adjusted to facilitate central venous return 1.
From the FDA Drug Label
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 to administer 0.25 to 2 g/kg of mannitol as a 15% to 25% solution over 30 to 60 minutes 2.
- Key considerations:
- Careful evaluation of circulatory and renal reserve prior to administration
- Monitoring of fluid and electrolyte balance, body weight, and total input and output
- Evidence of reduced cerebral spinal fluid pressure must be observed within 15 minutes after starting infusion
- Contraindications and warnings: renal complications, fluid and electrolyte imbalances, and central nervous system toxicity 2
From the Research
Traumatic Brain Injury Management
Doctors' Orders
When managing traumatic brain injury (TBI), specific doctors' orders should be written on the chart to ensure optimal care. These orders may include:
- Maintaining appropriate cerebral perfusion pressure (CPP) by increasing mean arterial pressure, decreasing intracranial pressure, or both 3
- Avoiding hypotension and hypoxia to prevent secondary injury 3
- Monitoring intracranial pressure (ICP) in all severe TBI patients 4
- Optimizing CPP according to individualized targets, such as those based on pressure-reactivity index 5
- Managing paroxysmal sympathetic hyperactivity, neuroprotective strategies, and prognostication 6
- Considering venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization 3
Specific Orders
Some specific orders that may be written on the chart include:
- Orders for blood pressure management, such as maintaining a mean arterial pressure (MAP) above a certain threshold 7
- Orders for ICP management, such as maintaining an ICP below a certain threshold 4
- Orders for CPP management, such as maintaining a CPP above a certain threshold 3, 7
- Orders for neuromonitoring, such as continuous monitoring of ICP, MAP, and CPP 6