What is the management of neurostorming in Traumatic Brain Injury (TBI)?

From the Guidelines

Neuro-storming in traumatic brain injury should be managed with a multi-modal approach targeting symptom control and addressing the underlying sympathetic surge, prioritizing interventions that reduce morbidity, mortality, and improve quality of life. The management of neuro-storming in traumatic brain injury (TBI) is crucial to prevent secondary brain injury and improve patient outcomes.

Key Interventions

• First-line pharmacologic management includes beta-blockers such as propranolol (20-60 mg every 4-6 hours) or labetalol (100-400 mg every 6-8 hours) to control tachycardia and hypertension, as recommended by recent guidelines 1.
• Gabapentin (300-1200 mg three times daily) or pregabalin (75-150 mg twice daily) are effective for controlling the sympathetic surge.
• For severe cases, opioids like morphine (2-4 mg IV every 4 hours) or fentanyl can help reduce pain and sympathetic drive.
• Benzodiazepines such as diazepam (5-10 mg every 6-8 hours) or midazolam may be added for additional sedation.
• Dexmedetomidine (0.2-0.7 mcg/kg/hr) is useful for refractory cases in ICU settings.

Non-Pharmacologic Interventions

• Minimizing environmental stimuli, maintaining a quiet environment, scheduling care activities to avoid clustering, and ensuring proper positioning are equally important.
• Regular monitoring of vital signs, temperature, and posturing is essential to evaluate treatment response.

Goal of Treatment

The goal is to break the cycle of sympathetic hyperactivity, which if left untreated can lead to increased intracranial pressure, metabolic demands, and secondary brain injury. Treatment typically continues for days to weeks, with gradual tapering as symptoms improve, and should be guided by the most recent and highest quality evidence, such as the ESICM/NACCS best practice consensus recommendations 1. In addition to these interventions, transferring patients to specialized neuro-intensive care units as soon as possible can improve outcomes, as highlighted in previous studies 1. However, the most recent and highest quality study 1 should be prioritized when making treatment decisions.

From the FDA Drug Label

In literature reports of severely head-injured patients in Neurosurgical ICUs, propofol injectable emulsion infusion and hyperventilation, both with and without diuretics, controlled intracranial pressure while maintaining cerebral perfusion pressure.

The management of neurostorming in Traumatic Brain Injury (TBI) may involve the use of propofol to control intracranial pressure while maintaining cerebral perfusion pressure. However, the provided text does not directly address the management of neurostorming. 2

From the Research

Management of Neurostorming in Traumatic Brain Injury (TBI)

• The management of TBI is based on protocol-based guidelines provided by the Brain Trauma Foundation, which aims to prevent secondary brain injury and ensure adequate oxygen delivery to injured brain tissue 3
• Achieving physiological targets such as oxygen, carbon dioxide, blood pressure, temperature, and glucose levels is crucial in TBI management, as is the role of effective prehospital care 4
• Maintaining cerebral perfusion pressure and ensuring adequate oxygen delivery to injured brain tissue is essential in the management of severe TBI 3
• Multimodality monitoring to assess intracranial pressure, cerebral oxygenation, cerebral metabolism, cerebral blood flow, and autoregulation is at the forefront of advances in TBI management 5
• Care of patients with TBI should occur in a dedicated critical care unit with subspecialty expertise, and management is based on the prevention of secondary brain injury from resultant trauma 5

Prevention of Secondary Brain Injury

• Adherence to the brain trauma foundation guidelines has overall improved outcomes in TBI patients 6
• Predictive models based on machine learning from continuous time series of intracranial pressure and partial brain tissue oxygenation can provide accurate predictions of physiologic crises events, offering the opportunity for earlier application of targeted interventions 6
• Preventive clinical algorithms can be used in conjunction with predictive models to prevent secondary brain injury 6

Treatment Options

• Decompressive craniectomy and therapeutic hypothermia are treatment options for TBI, although their effectiveness is still being studied 7
• Osmotherapeutic agents such as hypertonic sodium lactate solutions may also have a role in TBI management 4
• Normobaric hyperoxia is dangerous to the injured brain, and both high and low carbon dioxide levels should be avoided 4