(New) Guidelines for the

Management of Severe
Traumatic Brain Injury
A joint project of the
1. Brain Trauma Foundation
2. American Association of Neurological
Surgeons, Joint Section on Neurotrauma
and Critical Care

2000, Brain Trauma Foundation

ISBN 0-9703144-0-x

BTF and AANS,Joint Section on Neurotrauma and Critical Care Disunting dengan izin BTF oleh Prof.Gofar S
1
 INTRODUCTION
Traumatic Brain Injury (TBI), a clinical problem
treated frequently by neurosurgeons, is a major
cause of disability, death and economic cost to
our society.
One of the central concepts that emerged from
clinical and laboratory research is that all
neurological damage does not occur at the
moment of impact, but evolves over the insuing
hours and days.

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 INTRODUCTION
Further more, we now recognize the
deleterious effect of these various delayed
insults to the injured brain at the clinical
and biochemical levels

This has led to an interest in developing

the Guidelines for the Management of
Severe Traumatic Brain Injury

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These guidelines are comprised of fourteen topics :
1. Trauma system
2. Initial Management
3. Resuscitation of Blood Pressure and Oxygenation
4. Indication for ICP monitoring
5. Intracranial Pressure Treatment Threshold
6. Recommendations for ICP Monitoring Technology
7. Guidelines for Cerebral Perfusion Pressure (CPP)
8. Hyperventilation
9. The Use of Mannitol
10. The Use of Barbiturates
11. The Role of Steroids
12. Critical Pathway for the Treatment of Established Intracranial
Hypertention
13. Nutrition
14. The Role of Antiseizure Prophylaxis Following Head Injury

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 Degrees of Certainty
In assessing degree of certainty associated with a particular
recommendations, the following terminology is the most widely
accepted :

1. STANDARDS : represent accepted principles of

patient management that reflect a high
degree of clinical certainty
2. GUIDELINES : represent a particular strategy or range
of management strategies that reflect a
moderate degree of clinical certainty
3. OPTIONS : are the remaining strategies for
patient management for which there
is unclear clinical certainty.

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 Classification of Evidence
When assessing the value of therapies or interventions, the available data is
classified into one of three catagorties according to the following criteria :

1. Class I evidence: PRCT (Prospective Randomized Controlled Trial)

The gold standard of clinical trials.

2. Class II evidence: Clinical studies in which data was collected

prospectively, and retrospective analysis that were
based on clearly reliable data.
(observational studies, cohort studies, prevalence
studies and case control studies).

3. Class III evidence: Most studies based on retrospectively collected data

(clinical series,databases,case reviews,case
reports,experts opinion with some support from
animal studies)

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Correlation Between Evidence and
Recommendations
1. STANDARDS : are generally based on Class I evidence.
However, strong Class II evidence may form
the basis for a standard.

2. GUIDELINES : are usually based on Class II evidence or a

preponderance Class III evidence

3. OPTIONS : are usually based on Class III evidence and

are clearly much less useful except for
educational purposes and in guiding future
studies

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 TRAUMA SYSTEM
RECOMMENDATION :
1. Standards : Insufficient data to support a treatment
standards
2. Guidelines : All regions should have an organized
trauma care system
3. Options : ACS Committee on Trauma :
Neurosurgeons should have an organized and responsive system of care
for patients with neurotrauma.

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 TRAUMA SYSTEM
Trauma system development and
GUIDELINES
organization and better injury prevention
appear to be lowering death and disability
from intentional and unintentional injury
Trauma System should include:
Prehospital Care Emergency Room of
Community Hospital Trauma Center

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 TRAUMA SYSTEM
Options : ACS Committee on Trauma :
Neurosurgeons should have an organized and responsive system of
care for patients with neurotrauma.
Trauma facilities should include neurosurgery service,an in-house
trauma surgeon,operating room,icu,laboratory facilities,and a CT-
Scanner.
In rural area without neurosurgeon, a surgeon should be trained to
perform accurate neurosurgical assessment,initiate immediate
neurotrauma care and perform live-saving surgical treatment of
intracerebral hematoma in a deteriorating patient.

Rumah Sakit yang tidak mempunyai fasilitas dan tenaga terlatih

untuk pertolongan terhadap penderita neurotrauma seyogianya
menolak untuk menolong secara khusus.

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 INITIAL MANAGEMENT
RECOMMENDATION :
1. Standards : Insufficient data to support a treatment
standards

2. Guidelines : Insufficient data to support a treatment

guidelines
3. Options :

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 INITIAL MANAGEMENT
RECOMMENDATIONS :
3. Options :
a. The first priority for the head-injured patient is complete and rapid
physiologic resuscitation
b. No spesific treatment should be directed at intracranial
hypertension in the abcense of tranStentorial herniation or
progressive neurologic deterioration not attributable to
extracranial explanation
c. If tranStentorial herniation or progressive neurologic deterioration
not attributable to extracranial explanation are present treat
agressively : hyperventilation, mannitol, sedation and
neuromuscular blockage.

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 INITIAL MANAGEMENT
Sedation :
There is evidence that sedation and pharmacologic relaxation
influence the initial evaluation and treatment of neurotrauma
patients.

No studies on the influence of sedation on outcome of severe TBI

Decisions to use sedation and the choice of agents are left to the
practitioner

Neuromuscular Blockade
Neuromuscular blockade should be reserve for specific indications
(e.g: intracranial hypertension, transport etc) rather than routinely
administered to severe head injury patients.

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 INITIAL MANAGEMENT
Blood Pressure and Oxygenation
Class II evidence : hypotension (systolic BP < 90 mmHg) and apnea
/ cyanosis / PaO2 < 60 mmHg by arterial blood gas analysis are
associated with increased mortality and morbidity

Enhanced blood pressure resuscitation improves outcome from

severe head injury.

Mannitol
Two Class I studies and one Class II study support mannitol in ICP
control

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 INITIAL MANAGEMENT
Hyperventilation
Hyperventilation cerebral vasoconstriction reduced CBF
provides reduction in ICP

Research : CBF during the first day after injury is less than half of
normal individuals.
Aggressive hyperventilation reduced CBF further but will not
consistently reduce ICP loss of autoregulation

CBF is not directly related to ICP

Thus, limiting the use of hyperventilation following head injury may

help improve neurologic recovery following injury or at least avoid
iatrogenic cerebral ischemia.

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 INITIAL MANAGEMENT
Committee Consensus
The management of Head Injury patient prior to ICP monitoring be predicted
on clinical evidence of intracranial hypertension as manifest by signs of
herniation.

Signs of herniations include :

1. Unilateral or bilateral pupillary dilatation
2. Asymmetric pupillary reactivity
3. Motor posturing (extensor or flexor posturing)
4. Other evidence of deterioration of the neurologic examination

ATLS evaluation remains the first priority

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 INITIAL MANAGEMENT
Management in the Absence of Clinical
Signs Herniation
In the absence of clinical evidence of transtentorial herniation
sedation and pharmacologic relaxation should be used when
indicated for safe and efficient patient transport.

Pharmacologic relaxation has the undesirable effect of limiting the

neurologic exam to the pupils and therefore its use should be limited
to situation where sedation alone is not sufficient to optimized safe
and efficient patient transport and resuscitation.
When used, short acting agents are strongly preferred.

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 INITIAL MANAGEMENT
Management in the Presence of Clinical
Signs Herniation
When there is evidence of transtentorial herniations aggressive
treatment of intracranial hypertension is indicated.

Hyperventilation is easily accomplished by increasing the ventilator

rate (and does not depend on or interfere with successful volume
resuscitation)

Because hypotension can produce both neurologic deterioration and

intracranial hypertension , the use of mannitol is less desirable
unless adequate volume resuscitation has been accomplished.

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 INITIAL MANAGEMENT
SUMMARY :
The fundamental goals of resuscitation of severe TBI
patient are the restoration of circulating volume, blood
pressure, oxygenation and ventilation

Initiate maneuvers that serve to lower ICP and do not

interfere with these aims as early as possible during
resuscitation of any patient of head injury

Hyperventilation and mannitol should be reserved for

patients who show signs of intracranial hypertension

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 RESUSCITATION OF BLOOD
PRESSURE AND OXYGENATION
RECOMMENDATION:
1. Standards : insufficient data
2. Guidelines : Hypotension (SBP<90mmHg) or Hypoxia or
Oxygen saturation < 90% or PaO2 < 60 mmHg should be
corrected immediately.

3. Options : MAP should be maintained above 90 mmHg

through the infusion of fluids to maintain CPP > 70 mmHg.
Patients with GCS < 9 who are unable to maintain airway or
remain hypoxic despite supplemental O2 require air way to be
secured endotracheal intubation

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 RESUSCITATION OF BLOOD
PRESSURE AND OXYGENATION
Airway Management
Prehospital intubation is associated with significantly enhanced
survival of TBI patients.
Resuscitation Fluids
- The American College of Surgeons advocates the rapid infusion of
two liters of Ringers lactate or normal saline as an initial
resuscitative crystalloid bolus.
- ATLS course advise the judicious use of fluid in treating TBI
patients
- Hypertonic saline and mannitol have been advocated as
resuscitation fluids in addition to the reduction of ICP

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 HYPERVENTILATION
RECOMMENDATIONS :
1. Standards
In the absence of increased ICP , chronic prolonged
hyperventilation therapy (PaCO2 25 mmHg) should be avoided
after TBI
2. Guidelines
The use of prophylactic hyperventilation (PaCO2 35 mmHg)
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 reduced.
3. Options
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, paralyses, CSF
drainage and osmotic diuretics Not valid anymore
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 THE USE OF MANNITOL
RECOMMENDATION :
A. STANDARDS
There is insufficient data to support treatment standards
B. GUIDELINES
Mannitol is effective for control of raised intracranial pressure after severe head
injury (0.25g 1 g / kg body weight)
C. OPTIONS
Mannitol is indicated prior to ICP monitoring if there are signs of TH or progressive
neurological deterioration. However hypovolemia should be avoided by fluid
replacement.

Serum osmolarity should be kept below 320 mOsm because of concern of renal
failure

Euvolemia should be maintaine by adequate fluid replacement

Intermittent bolus may be more effective then continuous infusion

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 THE ROLE OF STEROIDS
RECOMMENDATION :
A. STANDARDS
The use of steroids is not recommended for improving outcome or
reducing ICP in patient of severe head injury

B. GUIDELINES
None

C. OPTIONS
None
50% incidence of GI bleeding ; 85% incidence of hyperglycemia

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THE USE OF BARBITURATE IN THE CONTROL
OF INTRACRANIAL HYPERTENSION

RECOMMENDATIONS :
A. STANDARDS
There are insufficient data to support a treatment standards
B. GUIDELINES
High-dose barbiturate therapy may be considered in
hemodynamically stable salvageable head injury patients with
intracranial hypertension refractory to maximal medical and
surgical ICP lowering therapy
Barbiturate is not recommended for the prophylactic treatment of ICP.
Its use be limited to critical care providers with appropriate systemic
monitoring.
When barbiturate coma is utilized, arteriovenous oxygen saturation
should be monitored to prevent oligemic cerebral hypoxia
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 NUTRITION
RECOMMENDATION :
A. STANDARDS
There is insufficient data to support treatment standards

B. GUIDELINES
Replace 140% of resting metabolism expenditure in non-paralyzed
patients and replace 100% of resting metabolism expenditure in
paralyzed patients using enteral or parenteral formulas containing at least
15% of calories as protein by the seventh day after injury

C. OPTIONS
The preferable option is use of jejunal feeding by
gastrojejunostomy due to ease of use and avoidance of gastric
intolerance

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