What are the guidelines for the acute management of Traumatic Brain Injury (TBI)?

From the Guidelines

The acute management of traumatic brain injury (TBI) should prioritize maintaining adequate cerebral perfusion pressure (CPP) by ensuring a systolic blood pressure above 100 mmHg and oxygen saturation above 90%, as recommended by the most recent guidelines 1.

Key Interventions

• Secure the airway in patients with a Glasgow Coma Scale (GCS) score below 8, typically through rapid sequence intubation using medications like etomidate (0.3 mg/kg) and rocuronium (1 mg/kg) 1.
• Maintain normocapnia with PaCO2 between 35-40 mmHg.
• For elevated intracranial pressure (ICP), administer mannitol 0.5-1 g/kg IV over 20 minutes or hypertonic saline 3% at 0.5-1 mL/kg/hr 1.
• Seizure prophylaxis with levetiracetam 500 mg IV twice daily for 7 days is recommended for moderate to severe TBI.
• Maintain normothermia, targeting a temperature below 37.5°C, using acetaminophen 650 mg every 4-6 hours and cooling blankets if necessary.
• Keep the head elevated at 30 degrees to promote venous drainage.
• Obtain an urgent CT scan to identify surgical lesions requiring intervention.
• Maintain euglycemia (blood glucose 80-180 mg/dL) and correct coagulopathy if present.

Transfer and Transportation

• Patients with a GCS ≤ 8, a significantly deteriorating conscious level, or requiring transfer should undergo tracheal intubation and mechanical lung ventilation 1.
• The transfer of responsibility for the patient’s care should be agreed by both parties.
• Avoid transfer of a hypotensive or hypoxic patient.
• Patients with a brain injury should be accompanied by a clinician with appropriate training and experience in the transfer of patients with acute brain injury.

Monitoring and Education

• Monitoring during transport should adhere to published guidelines 1.
• The transfer team should be in possession of a mobile phone for urgent communication.
• Education, training, and continuous audit are crucial and help to maintain standards of transfer.

From the FDA Drug Label

Reduction of intracranial pressure and brain mass. Adults: 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 recommended dosage of mannitol for acute management of traumatic brain injury (TBI) is:

• Adults: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30 to 60 minutes
• Pediatric patients: 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over 30 to 60 minutes 2 Key considerations:
• Monitor serum sodium and potassium levels during mannitol administration
• Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol
• Discontinue mannitol if renal, cardiac, or pulmonary status worsens, or CNS toxicity develops 2

From the Research

Acute Management of Traumatic Brain Injury (TBI)

• The primary goal of acute TBI management is to prevent secondary injury by maintaining appropriate cerebral perfusion pressure (CPP) and avoiding hypotension and hypoxia 3.
• CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both, with the goal of achieving euvolemia and avoiding hypotension 3.
• Other important considerations in acute TBI management include:
  • Venous thromboembolism
  • Stress ulcer
  • Seizure prophylaxis
  • Nutritional and metabolic optimization 3

Hyperosmolar Agents for Elevated Intracranial Pressure

• Two commonly used hyperosmolar agents for treating elevated intracranial pressure in TBI are mannitol and hypertonic saline (HTS) 4, 5, 6, 7.
• Studies have compared the effectiveness of mannitol and HTS in reducing intracranial pressure and improving outcomes in TBI patients:
  • A meta-analysis found that HTS was more effective than mannitol in controlling intracranial pressure, but there was no significant difference in functional outcome or mortality 5.
  • Another study found that HTS had significantly lower treatment failure and lower intracranial pressure 30-60 minutes after infusion termination compared to mannitol, but no significant difference in favorable outcome or mortality 7.
  • A review of existing research suggested that HTS is an effective alternative to mannitol for reducing intracranial pressure, but further research is needed to determine superiority 6.

Treatment Outcomes and Considerations

• The choice of hyperosmolar agent may depend on individual patient characteristics and center preferences, with some studies suggesting that center characteristics are a more important driver of the choice of agent than patient characteristics 4.
• Treatment outcomes, including intracranial pressure reduction, cerebral perfusion pressure, and mortality, may vary depending on the hyperosmolar agent used and the specific patient population 4, 5, 6, 7.
• Further research is needed to fully understand the effects of different hyperosmolar agents on outcomes in TBI patients and to inform evidence-based treatment guidelines 4, 5, 6, 7.