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BTF
A joint project of the Brain Trauma Foundation
American Association of Neurological Surgeons(AANS)
Congress of Neurological Surgeons(CNS) AANS/CNS Joint Section on Neurotrauma and Critical

Care

TBI(Traumatic Brain Injury)

Incidence 56430/100,000 Male: female = 3:2 60% occur in 2040 yr age High mortality and morbidity

Majority of deaths occur in the first 72 hrs

Commonest cause is road traffic accidents

Introduction
Major cause of disability, death and economic cost to

our society.
Damage from TBI not only at the time of impact but

evolves over a time of hours and days.

Reduction in mortality from 50%--35%--25%

subsequent to the use of Evidence Based Protocols that emphasize monitoring and maintaining adequate cerebral perfusion

BTF Guidelines for management TBI

1st Edition: 1995
2nd Edition: 2000 3rd Edition: 2007

6 new chapter Standard Level I Guidelines Level II Options Level III

Topic
Blood Pressure and ICP Thresholds

Oxygen Hyperosmolar Therapy Prophylactic Hypothermia Infection Prophylaxix DVT Prophylaxix Indications for ICP monitoring ICP Monitoring Ttechnology

Brain Oxygen monitoring

and Threshold Anaesthetics, Analgesics, and Sedatives Nutrition Antiseizure Prophylaxis Hyperventilation Steroids

Levels of Recommendations
Level I : Recommendations are based on the

strongest evidence, represent principles of patient management that reflect a high degree of clinical certainty.
Level II : Recommendations reflect a moderate

degree of clinical certainty.

Level III : Recommendations for which the

degree of clinical certainty is not established

Blood Pressure and Oxygen

Level I: Insufficient Data
Level II: BP should be monitored and Hypotension

<90mm of Hg avoided.
Level III: Oxygenation should be monitored and

Hypoxia(PaO2 <60mm of Hg or SpO2 <90%) avoided

Scientific Foundation (data collected from TCDB)

Hypoxemia occurred in 22.4% of severe TBI

mortality and

morbidity
In non-Hypoxemic patient mortality was 14.3% with a 4.8%

rate of severe disability

Patient with O2 saturation <60% mortality was 50% and all

survivors severely disabled.

 A single episode of Hypotension (SBP <90mm of Hg) was

associated with increased morbidity and doubling of mortality Vs patients without hypotension.
Relative risk of mortality: 2.05(one episode of Hypotension)

:8.10(2 or more episode)

SBP <90mm of Hg and PaO2 <60mm of Hg must be avoided.

Key Issues
Ethical : Manipulative investigation Level of hypoxia/hypotension that correlates with poor

outcome
Treatment threshold
Optimum resuscitation protocols for hypoxia and

hypertension
Specification of target values

Hyperosmolar Therapy
Level I: Insufficient Data
Level II: Mannitol 0.25-1gm/kg BW effective for raised

ICT( SBP <90mm of Hg should be avoided)

Level III: Restrict Mannitol prior to ICP monitoring if

signs of Transtentorial Herniation or progressive neurological deterioration not attributable to extra cranial cause.

Possible MOA of Mannitol

Immediate Osmotic

Plasma expansion
hematocrit Blood viscosity

Delayed 15-30min
Persists for 90min-6hrs Risks: Arterial hypotension Sepsis Nephrotoxicity

deformability of erythrocyte
CBF and O2 delivery

Hypertonic Saline
Osmotic mobilization of water across BBB

Cerebral water content

HS as a bolus infusion may be an effective adjuvent or

alternative to mannitol
However current evidence is not strong enough to make

recommendation

Key Issues
RCT to determine relative benefit of HS Vs mannitol Optimal administration and concentration of HS

Validation of use single high dose mannitol

Efficacy of prolonged hypertonic therapy for raised

ICT, especially in relation to outcome.

Prophylactic Hypothermia
Level I: Insufficient Data
Level II: Insufficient Data Level III: Not significantly associated with

mortality Vs normothermic, however some findings suggest that a greater mortality risk if target temp maintained for >48 hrs

 Evidence from 6 moderate quality RCT

Not clearly demonstrate hypothermia with significant

reduction in mortality.
Hypothermia may have higher chances of reducing

mortality and better GOS(Glasgow Outcome Scale) score of 4 or 5 if cooling maintained for >48 hrs.

Key Issues
Inadequate or poorly described randomization Inability to rule out confounding of treatment effects

No blinding of outcome assessors

Inadequate management of missing outcome data Improvement : Independent event monitoring committees

: Larger sample size/Multiple centre : Increase standardization / Control group

Infection Prophylaxis
Level I: Insufficient Data
Level II: Periprocedural antibiotics (Intubation) to

reduce incidence of Pneumonia

Level III: Routine Ventricular catheter exchange or

prophylactic antibiotic use for its placement is not recommended.

 Ventriculostomies and other ICP monitors should be

placed under sterile condition to close drainage systems minimising manipulation and flushing
No support for use of prolonged antibiotics for systemic

prophylaxis in intubated TBI patient

A single study(Sirvent et al) supports the use of a short

course of antibiotic at the time of intubation of pneumonia

the risk

Key Issues
Lack of RCTs with sufficient number of TBI Trials including those with antibiotic impregnated

catheters, would be both ethical and useful

DVT Prophylaxis
Level I: Insufficient Data Level II: Insufficient Data Level III: Graduated Compression stockings or intermittent

pneumatic compression(IPC) unless lower extremity injuries (till ambulation) : LMWH/ low dose UH should be used in combination with mechanical prophylaxis ( risk of expansion of ICH)

 Risk of DVT in absence of DVT prophylaxis 20% after

severe TBI
Any decision must weigh efficacy against harm

(Intracranial/systemic bleeding)
No reliable data for pharmacological prophylaxis and

medication choice or optimal dosing regimen based on current evidence

Key Issues
An RCT of mechanical prophylaxis Vs with addition of

pharmacological prophylaxis in severe TBI is needed

Specifically address the issue of WHEN, WHAT and

HOW MUCH
Comparison of risk in specific traumatic intracranial

lesion(eg. Contusion Vs SDH Vs SAH etc.)

Vena Cava Filters

Indications of ICP monitoring

Level I: Insufficient Data
Level II: ICP should be monitored in all severe TBI(GCS

3-8) and an abnormal CT

Level III: Patient with severe TBI with normal CT with

2 or more of followig features present : Age >40 years : Uni/Bilateral motor posturing : Systolic BP <90 mm of Hg

 ICP data useful in predicting outcome and guiding

therapy
There is an improvement in outcomes in those patients

who respond to ICP lowering therapy

Treating elevated ICP without monitoring can be

deleterious and result in a poor outcome

Key Issues
RCT of ICP monitoring with or without treatment Further studies on sequential normal CT in severe TBI

patients and the incidence of ICH and evolving lesions would be useful to identify a group that may not require ICP monitoring and treatment.

ICP Monitoring Technology

Accurate, Reliable, Cost effective and cause

minimum patient morbidity.

AAMI (Association of the Advancement of Medical

Instrumentation) standard device should have following specifications: > Pressure range 0-100 mm Hg > Accuracy + 2 mm Hg in range of 2-20 mm Hg > Maximum error 10% in range of 20-100mm Hg

Ranking of ICP Monitoring Technology

1. Intraventricular devices: fluid-coupled catheter with

external strain guage

2. Intraventricular devices: micro strain gauge or fibroptic

3. Parenchmal pressure transducer devices

4. Subdural devices 5. Subarachnoid fluid coupled devices 6. Epidural devices

Key Issues
Specification for ICP devices should be reviewed in the

context of what data is useful in management of patient that receive ICP monitoring
Research about parenchymal monitoring near a

contusion site provide ICP data that improve ICP management and outcome as compared to other sites
To develop multiparametric ICP devices that can

provide measurement of Ventricular CSF, parenchymal ICP and other advanced monitoring parameters

ICP Threshold
Level I: Insufficient Data
Level II: Treatment should be started with ICP

thresholds > 20 mm Hg
Level III: A combination of ICP values, and clinical

and brain CT findings should be used to determine treatment

 Patient can herniate at ICP <20-25 mm Hg

Depends on intracranial mass lesion Therefore at all points any chosen threshold must be

closely and repeatedly corroborated with the clinical exam and CT imaging in an individual patient

Key Issue
Identify more concrete treatment thresholds for ICP

: To develop a method to estimate Herniation Pressure : To determine the critical values for other parameters

Cerebral Perfusion Threshold

Level I: Insufficient Data
Level II: Aggressive attemps to maintain CPP >70 mm

Hg with fluids and pressors should be avoided( Risk of ARDS)

Level III: CPP <50 mm Hg avoided

 Critical threshold for ischemia generally lies in the

realm of 50-60 mm Hg
General threshold in the realm of 60 mm Hg

fine tuning in patients not readily responding to basic treatment or with systemic contraindication to increase CPP manipulation
Routinely using pressors and volume expansion to

maintain CPP >70 mm Hg is not supported (systemic complications)

Key Issues
Minimally invasive, efficient, and accurate methods of

determining and following the relationship between CPP and autoregulation and between CPP and Ischemia in individual patient
RCT for influence on outcome of basing optimal CPP

on ischemia monitoring or on the quantitative indices of pressure autoregulation

Brain Oxygen Monitoring and Thresholds

Level I: Insufficient Data
Level II: Insufficient Data Level III: Jugular venous saturation <50% or brain

tissue oxygen tension < 15 mm Hg are treatment threshold

 Patients with multiple desaturation episode had 46-

71% mortality Vs patients without desaturation (18%)

Arterio-Jugular difference of O2 content (AJDO2) a

measurement of O2 extraction by tissue with high value (4.3 vol %) was associated with better prognosis
Brain tissue O2 saturation (PbtO2) <10-15 mm Hg for

duration >30 min associated with high mortality

Key Issues
Future investigation need to explore what specific

therapeutic strategies can improve the outcome and prevent these threshold (SjO2, AJDO2 or PbtO2) from being crossed.
For SjO2 monitors may require technological

improvements
Issues about probe placement w/r/t location of injury

Anaesthetics, Analgesics and Sedatives

Level I: Insufficient Data Level II : Prophylactic Barbiturates to induce burst

suppression EEG not recommended : High dose Barbiturates recommended to control elevated ICP refractory to maximum med/surg treatment : Propofol recommended for control of ICP, no long term improvement in mortality outcome

 Analgesics and Sedatives are common management

strategy for ICP control, but no evidence to support their efficacy in this regard and no positive effect on outcome
Attention must be paid to potential undesirable side

effects that might contribute to secondary injury

Key Issues
To identify subsets of patients who might respond

favorably to analgesic-sedative and/or barbiturate treatment

To identify alternative agents, drug combinations, and

dosing regimens
Research about novel sedative-anaesthetic

Dexmedetomidine

Nutrition
Level I: Insufficient Data Level II : Patients should be fed to attain full caloric

replacement by day 7 post-injury

 Starved TBI patient lose sufficient nitrogen to reduce

weight by 15% per week

100-140% replacement of Resting Metabolism Expenditure

with 15-20% nitrogen calories reduces nitrogen loss

It is not established that any method of feeding is better

than another
Full nutrition replacement be instituted by day 7 post-

injury

Key Issues
Studies to determine if specific nutritional formulations

and addition of vitamins and other supplements can improve outcome

Timing of feeding, Rate of achievement of target caloric

intake and method of delivery

Antiseizure Prophylaxis
Level I: Insufficient Data
Level II : Prophylactic use of Phenytoin or Valproate is

not recommended for preventing late posttraumatic seizures(PTS) : Indicated to decrease the incidence of early PTS (within 7 days of injury), However early PTS is not associated with worse outcome

 Majority of studies do not support the use of prophylactic

anticonvulsants for prevention of late PTS

Routine use later than 1 week not recommended

For late PTS patients should be approached as new onset

seizures
Phenytoin shown to reduce early PTS, Valproate has

comparable efficacy to Phenytoin but may be associated with higher mortality

Key Issues
Additional studies about effect on outcome after

reduction in early PTS

Study should utilize continuous EEG monitoring to

identify seizures
Study about neuroprotective agents eg. MgSO4 and

other NMDA receptor antagonists

Hyperventilation
Level I: Insufficient Data Level II : Prophylactic hyperventilation (PaCO2 of 25

mm Hg or less) is not recommended

Level III : Recommended as a temporizing measure

for reduction of elevated ICP : Avoided during first 24 hrs when CBF is often critically reduced : If hyperventilation is used, SjO2 or PbtO2 measurement are recommended

 Hyperventilation reduces ICP by causing cerebral

vasoconstriction, and so the CBF

Because of vasoconstriction, risk of ischemia with

aggressive hyperventilation
Poorer outcome at 3-6 months when prophylactic

hyperventilation was used compared to when not used

Key Issues
Further RCT need to be conducted for

: How does short term hyperventilation affect outcome

: Effect of moderate hyperventilation in specific subgroup

: Critical levels of PaCO2/CBF and outcome

Steroids
Level I : Not recommended for improving outcome or

reducing ICP
: High dose methylprednisolone is associated with increased mortality and is contraindicated

 Trials in TBI with different steroids (synthetic

glucocorticoid, triancinolone, 21-aminosteroid tirilazard, dexamethasone, methylprednisolone) None has indicated an overall beneficial effect on outcome
One trial was halted when interim analysis showed

increased mortality

Key Issues
If new compounds with different mechanism of

actions are discovered, further study may be justified

Hyperventilation

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