TBI
Traumatic Brain Injury Treatment
Powerchart (HUGO Orders Sets) – for TBI:
– CRIT CARE – Traumatic Brain Injury (module)
– CRIT CARE – Traumatic Brain Injury with Persistent Elevation in ICP (module)
– CRIT CARE – Induction of Therapeutic Hypothermia (module)
This Neuro Flashcard has been adapted from the University of Calgary’s Traumatic Brain Injury Protocol and edited to the protocols at London Health Sciences Centre (Victoria Hospital – CCTC)
| Tier 1: Cerebrovascular Stability, Sedation & Ventricular Drainage | ||
| Monitoring · ICP (EVD/Codman/Licox – by NSx) · Arterial BP · CVP · PbtO2 (consider) · SjVO2 (consider) · Cerebral metabolism (microdialysis) · Blood glucose q1h · Baseline SSEP (consider) · Consider CEEG |
General Management · HOB @ 30 degrees as spinal precautions allow · Nutrition as per DCCM · DVT prophylaxis · Avoid hypoglycemia (<4.0mmol/L) & hyperglycemia (>11mmol/L) |
Initial Goals · CPP 60 – 70 mmHg · ICP < 20 mmHg · PaCO2 35 – 40 mmHg · PaO2 80 – 120 mmHg · PbtO2 > 20 mmHg · SjVO2 > 60% · Brain temperature 26-37.5OC · Euvolemia · Cardiac Index (CI) > 3.0 L/min/m2 · Hgb > 90 g/dl |
| · Seizure Prophylaxis: In absence of CEEG, prophylactic Dilantin recommended (7 days) o Loading dose – 18 mg/kg IV @ a rate no greater than 50 mg/min (hypotension from propylene glycol) o Maintenance dose – 5-7 mg/kg IV q8h |
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| Treatment of ICP > 20 mmHg: Institute concomitantly provided no surgically remediable space occupying lesion on CT · Fentanyl 25-150 ug/h IV infusion · Propofol 0-50 ug/kg/h infusion for VAMAAS goal of 1A · Draw ABG as per TBI oxygen protocol to ensure PaCO2 Goals are met · CPP Support: o If CPP < 60 mmHg for > 10 min & CVP ≤ 8 give NS 500 ml IV stat over 10 min o If CPP < 60 mmHg for > 10 min & CVP > 8 start Levo @ 0-0.5 ug/kg/min o If CPP < 50 mmHg for any duration & CVP ≤ 8 give NS 500 ml IV stat over 10 min o If CPP < 50 mmHg for any duration & CVP > 8 start Levo @ 0-0.5 ug/kg/min o ** NOTIFY MD OF ANY INTERVENTIONS DONE ASAP** o Good CPP is Critical; § If low CPP is related to high ICP, EVD drainage may be implemented in addition to the above actions. (insertion by neuro surgery) · EVD Drainage: IF ICP > 20 mmHg for > 10 min open EVD @ 15 cm H2O x 15 min · If body temperature is > 37.5 start acetaminophen @ 650mg q4h (provided no liver failure) · If brain temperature is > 37.5 despite start acetaminophen, consider cooling blanket · IF ICP NOT CONTROLLED BY ABOVE MEASURES: o Stat CT to rule out space occupying lesions & Notify Neurosurgery o If no space occupying lesion, proceed to tier 2 ONLY after discussion with MD |
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| Tier 2: Paralysis, Osmol Therapy, Mild Hypothermia, Mild Hyperventilation | ||||
| 1. Cisatracurium: · Loading Dose = 0.2mg/kg IV Followed by 1-2 mcg/kg/hr (20-37.5mg/hr) |
2. Hypertonic Saline 3%: · 2ml/kg q2h prn for ICP >20 x 10 min · Max Na+ 16mmol/L Alternate = Mannitol Calculations: |
3. Mild Hypothermia · Goal Temp = 350C 4. Mild Hyperventilation
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| Tier 3: Decompression, Moderate Hypothermia and Barbiturates | ||||
| 1. Ensure all physiologic goals & therapeutic goals from tier 1 & 2 are optimized | 2. Consider repeat SSEP | 3. Consider experimental protocols for decompressive craniectomy (Page on call Neurocritical Care) | ||
| 4. Induce hypothermia to 340C | 5. Consider ICP threshold of <25 and strict CCP Goals | 6. Consider pentobarb coma · 10mg/kg over 10min, then 5mg/kg IV q1H x3, then 1mg/kg/h IV infusion · Dose should be titrated to the minimal amount that controls ICP · Discontinue other sedation once in pentobarb coma · Paralytics not usually needed once pt on barbiturate Tx |
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| · If ICP >25mmHg on barbiturates, obtain EEG monitoring to ensure burst suppression· If ICP <20mmHg for 48 hrs post barbiturates, taper dose over 48-72 hrs | ||||