Severe Traumatic Brain Injury Guidelines

• Provide a general approach to patients with Severe Traumatic Brain Injury requiring ICU level of care. Please note that this guideline does not replace frequent and timely communication with the clinical care team and escalation to neurosurgery and/or neurocritical care as indicated.

• PaO2 80 mmHg to 200 mmHg
• PaCO2 35-40 mmHg *Not a candidate for permissive hypercapnia.
• End tidal CO2 monitoring on all patients – Correct hypercapnia based on ETCO2, however Do NOT decrease minute ventilation based on a low ETCO2, confirm hypocapnia with blood gas.
• Place arterial line
• In the setting of elevated ICP increase MAP to meet cerebral perfusion pressure goal (>60)
• ICP
  • ICP limit 22 mmHg
  • Intervene for ICP >22 mmHg for 5 minutes or longer without stimulation.
  • If ICP elevated over 15 minutes despite interventions as below, page neurosurgery.
• CPP Goal >60- mmHg
• ICP monitor for patients with GCS 8 or less and abnormal head CT, hypotension to target Maintain normothermia 36-38 °C
• Glucose 80-180- normal preferred
• Serum Sodium 135-145 unless as described in Intracranial Hypertension Section
• INR <1.5 Platelets >100, obtain and correct Platelet Function Analysis (PFA)
• Obtain, correct, and repeat TEG as necessary per TICU and NRS
• Hemoglobin >7
• Consider EEG to rule out nonconvulsive seizures for persistent depressed GCS

• Daily documentation of neurological exam including pupil exam and whether patient is posturing, withdraws to noxious stimuli, localizes, purposeful movement etc. as small changes in exam can have
• drastic implications in clinical status, prognosis and management.
• Maintain head elevation of 30° unless log roll precautions are in place. Can place in reverse
• Trendelenburg.
• Order hourly neuro checks on Cerner, as well as pupillometry, for at least 24 hours.
• Seizure prophylaxis for 7 days with 1g BID of levetiracetam (renally adjusted)
• Propranolol if heart rate and blood pressure/ CPP tolerates.
• Discontinue C-Collar per guidelines.
• Ensure CTA head and neck have been obtained to screen for BCVI (blunt cerebrovascular injury)
• GI prophylaxis with famotidine or pantoprazole
• Chemical thrombophylaxis as per TICU guidelines under TBI section

• ICP limit 22 mmHg Intervene for ICP >22 for 5 minutes or longer without stimulation.
• Use lowest tier that is needed to maintain ICP within goal
• Can advance tier prior to exhausting all modalities on each lower tier
• May need to skip to higher tier if clinically indicated

• Immediately examine the patient to assess cause (perform full neurological exam including noxious stimuli and pupil diameter as well as light reactivity).
• If you suspect acute herniation (e.g. new dilated pupil, asymmetric neurological exam, new deficit, hypertension and bradycardia):
  • Immediately call TICU attending, TICU fellow and Neurosurgery
  • Hyperventilate to a rate of 30 for NO MORE than 60 minutes. PaCO2 30-32 mmHg.
  • Bolus hyperosmolar therapy PRIOR to obtaining CT imaging (with approval by TICU attending, fellow and/or neurosurgery (consider mannitol, 3% NaCl or 23.4% NaCl 30mL slow IV Push over 2-10 min)
  • Obtain CT Brain

• Consider Amantadine or Modafinil for patients with decreased level of consciousness after 2 weeks of injury.

• Marked by sympathetic hyperactivity inducing tachycardia, hypertension, hyperthermia, tachypnea or ventilator dyssynchrony, agitation. Typically last up to 30 minutes with near complete resolution in between episodes
• Consider sepsis as possible etiology of symptoms
• Abortive therapy (consider airway status when giving sedatives and analgesics):
  • Boluses of IV opiates, propofol and/or benzodiazepines

• Propranolol should be started in all TBIs with hemodynamic stability. Ensure hold parameters are in place
• α agonists (Dexmedetomidine, clonidine)
• Gabapentin, bromocriptine for hyperthermia and diaphoresis, baclofen for spasticity and dystonia
• Consider longer acting opiates and benzodiazepines for persistent storming as appropriate after careful discussion with clinical care team

Hawryluk GWJ, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2019 Dec;45(12):1783-1794.

Eduard Valdes, Taolin Fang, Prachi Bhatt, Michael Boffa, JenniferFrontera
Optimal Dose of Levetiracetam for Seizure Prophylaxis in Neurocritical Care Patients (4877)
Neurology Apr 2021, 96 (15 Supplement) 4877;

Carney N, Totten AM, O’Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432

Kakehi S, Tompkins DM. A Review of Pharmacologic Neurostimulant Use During Rehabilitation and Recovery After Brain Injury. Ann Pharmacother. 2021 Oct;55(10):1254-1266.

Khellaf A, Khan DZ, Helmy A. Recent advances in traumatic brain injury. J Neurol. 2019 Nov;266(11):2878-2889. doi: 10.1007/s00415-019-09541-4

Meyfroidt G, et al. Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med. 2022 Jun;48(6):649-666. doi: 10.1007/s00134-022-06702-4

Naidech, A. M. (2022). Neurocritical Care (Cambridge Manuals in Neurology) (New ed.). Cambridge University Press.

Picetti, E., Catena, F., Abu-Zidan, F. et al. Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES). World J Emerg Surg 18, 5 (2023). https://doi.org/10.1186/s13017-022-00468-2

Ko A, Harada MY, Barmparas G, Thomsen GM, Alban RF, Bloom MB, Chung R, Melo N, Margulies DR, Ley EJ. Early propranolol after traumatic brain injury is associated with lower mortality. J Trauma Acute Care Surg. 2016 Apr;80(4):637-42. doi: 10.1097/TA.0000000000000959. PMID: 26808028.