Critical care management of severe traumatic brain injury in adults
Critical care management of severe traumatic brain injury in adults
Samir H Haddad 0
Yaseen M Arabi 1
0 Surgical Intensive Care Unit, Intensive Care Department, King Abdulaziz Medical City , PO Box 22490, Riyadh 11426, K.S.A
1 Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City , PO Box 22490, Riyadh 11426, K.S.A
Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the Guidelines for the Management of Severe Traumatic Brain Injury that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.
Traumatic brain injury; head injury; head trauma; critical care
Severe traumatic brain injury (TBI), defined as head
trauma associated with a Glasgow Coma Scale (GCS)
score of 3 to 8 , is a major and challenging problem
in critical care medicine. Over the past twenty years,
much has been learned with a remarkable progress in
the critical care management of severe TBI. In 1996, the
Brain Trauma Foundation (BTF) published the first
guidelines on the management of severe TBI  that
was accepted by the American Association of
Neurological Surgeons and endorsed by the World Health
Organization Committee in Neurotraumatology. The second
revised edition was published in 2000  with an update
in 2003, and the 3rd edition was published in 2007 .
Several studies have reported the impact of
implementation of guidelines-based management protocols for
severe TBI on patients treatment and outcome [5,6].
These studies have clearly demonstrated that the
implementation of protocols for the management of severe
TBI, incorporating recommendations from the
guidelines, is associated with substantially better outcomes
such as mortality rate, functional outcome scores, length
of hospital stay, and costs [7,8]. However, there is still
considerable and wide institutional variation in the care
of patients with severe TBI.
In general, TBI is divided into two discrete periods:
primary and secondary brain injury. The primary brain
injury is the physical damage to parenchyma (tissue,
vessels) that occurs during traumatic event, resulting in
shearing and compression of the surrounding brain
tissue. The secondary brain injury is the result of a
complex process, following and complicating the primary
brain injury in the ensuing hours and days. Numerous
secondary brain insults, both intracranial and
extracranial or systemic, may complicate the primarily injured
brain and result in secondary brain injury. Secondary,
intracranial brain insults include cerebral edema,
hematomas, hydrocephalus, intracranial hypertension,
vasospasm, metabolic derangement, excitotoxicity, calcium
ions toxicity, infection, and seizures [9,10]. Secondary,
systemic brain insults are mainly ischemic in nature
[9,11], such as:
Hence, it is now clear that only part of the damage to
the brain during head trauma is from the primary brain
injury, which is not amenable to alteration and cannot
be reversed. However, secondary brain insults are often
amenable to prevention or reversal.
The intensive care management of patients with
severe TBI is a dynamic process, starts in the
pre-hospital period, at the scene of the accident. During the early
stages of hospital care, the patients may be managed in
a variety of locations including emergency department,
the radiology department, and the operating room
before they are admitted to the Intensive Care Unit
(ICU). The continuum of acute care, during the
GOLDEN HOUR, from the time of injury through the
start of definitive care, should be ensured and based on
the guidelines and recommendations previously
mentioned. This review outlines the fundamental principles
of critical care management of patients with severe TBI
during their stay in the ICU. See Figure 1
Critical care management of severe TBI
Prior to arrival to the ICU, patients with severe TBI are
usually received, resuscitated and stabilized in
emergency department or operating room. Once the severely
head-injured patient has been transferred to the ICU,
the management consists of the provision of high
quality general care and various strategies aimed at
maintaining hemostasis with:
Monitoring of patients with severe TBI is essential for
the guidance and optimization of therapy. The rationale
of monitoring is early detection and diagnosis of
secondary brain insults, both systemic and intracranial.
Therefore, monitoring of patients with severe TBI must
comprise both general and specific neurologic
During neurointensive care of patients with severe TBI,
general parameters that are regularly monitored include
electrocardiography (ECG monitoring), arterial oxygen
saturation (pulse oxymetry, SpO2), capnography
(endtidal CO2, PetCO2), arterial blood pressure (arterial
catheter), central venous pressure (CVP), systemic
temperature, urine output, arterial blood gases, and serum
electrolytes and osmolality. Invasive or non-invasive
cardiac output monitoring may be required in
hemodynamically unstable patients who do not respond to fluid
resuscitation and vasopressors.
Intracranial pressure monitoring
The BTF recommends that intracranial pressure (ICP)
should be monitored in all salvageable patients with a
severe TBI and an abnormal computed tomography
(CT) scan. Also, ICP monitoring is indicated in
patients with severe TBI with a normal CT scan if two
or more of the following features are noted at
admission: age over 40 years, unilateral or bilateral motor
posturing, or systolic blood pressure (BP) < 90 mm Hg .
Based on physiological principles, potential benefits of
ICP monitoring include earlier detection of intracranial
mass lesion, guidance of therapy and avoidance of
indiscriminate use of therapies to control ICP, drainage of
cerebrospinal fluid (CSF) with reduction of ICP and
improvement of CPP, and determination of prognosis.
Currently, available methods for ICP monitoring
include epidural, subdural, subarachnoid, parenchymal,
and ventricular locations. Historically, ventricular ICP
catheter has been used as the reference standard and
the preferred technique when possible. It is the most
accurate, low-cost, and reliable method of monitoring
ICP . It also allows for continuous measurement of
ICP and for therapeutic CSF drainage in the event of
intracranial hypertension to control raised ICP.
Subarachnoid, subdural, and epidural monitors are less
accurate. ICP monitor is usually placed via the right side,
since in approximately 80% of the populations the right
hemisphere is the non-dominant, unless contraindicated
. However, it might be placed on the side with
maximal pathological features or swelling . Routine
ventricular catheter change or prophylactic antibiotic use
for ventricular catheter placement is not recommended
to reduce infection . However, ICP monitoring
devices are usually continued for 1 week; with daily
Haddad and Arabi Scandinavian Journal of Trauma, Resuscitation and
YES YES YES
NO NO NO
* ICP of 20-25 mm Hg is used as the treatment threshold.
examination of the CSF for glucose, protein, cell count,
clinical and brain CT findings should be used to
deterGram stain, and culture and sensitivity. Treatment for
mine the need for treatment .
intracranial hypertension should be started with ICP
Although there is no randomized, controlled trial
thresholds above 20 mm Hg. Additional to ICP values,
(RCT) that has been performed demonstrating that ICP
monitoring improves outcome or supporting its use as
standard; ICP monitoring has become an integral part
in the management of patients with severe TBI in most
trauma centers. However, there is contradicting evidence
about whether ICP monitoring improves outcome.
Several studies have demonstrated that ICP monitoring
reduced the overall mortality rate of severe TBI [14-21].
Other studies have not shown benefits from ICP
monitoring [22-24]. Moreover, a few studies have
demonstrated that ICP monitoring was associated with
worsening of survival [25,26]. Potential complications of
ICP monitoring include infection, hemorrhage,
malfunction, obstruction, or malposition. Recently, we reported
that in patients with severe TBI, ICP monitoring was
not associated with reduced hospital mortality, however,
with a significant increase in mechanical ventilation
duration, need for tracheotomy, and ICU length of stay
. In the Cochrane database, a recent systematic
review found no RCTs that can clarify the role of ICP
monitoring in acute coma whether traumatic or
nontraumatic . Nevertheless, there is evidence, and most
clinicians agree, to support the use of ICP monitoring in
severe TBI patients at risk for intracranial hypertension.
Absolute ICP values are independent predictors of
neurologic outcomes; however, refractory ICP and response
to treatment of raised ICP could be better predictors of
neurological outcome than absolute ICP values .
Treggiari et al. conducted a systematic review to
estimate the association between ICP values and patterns
and short- and long-term vital and neurological
outcome. Relative to normal ICP (< 20 mm Hg), raised ICP
was associated with elevated odds ratio (OR) of death:
3.5 [95%CI: 1.7, 7.3] for ICP 20-40, and 6.9 [95% CI: 3.9,
12.4] for ICP > 40 mm Hg. Raised but reducible ICP
was associated with a 3-4-fold increase in the ORs of
death or poor neurological outcome. Refractory ICP
pattern was associated with a dramatic increase in the
relative risk of death (OR = 114.3 [95%CI: 40.5, 322.3]) .
Jugular bulb venous oxygen saturation
The jugular venous oxygen saturation (SjvO2) is an
indicator of both cerebral oxygenation and cerebral
metabolism, reflecting the ratio between cerebral blood flow
(CBF) and cerebral metabolic rate of oxygen (CMRO2).
A retrograde catheterization of the internal jugular vein
(IJV) is used for SjvO2 monitoring. As the right IJV is
usually dominant , it is commonly used for
cannulation to reflect the global cerebral oxygenation .
Monitoring SjvO2 can be either continuous via a
fiberoptic catheter or intermittent via repeated blood
samples. In a prospective study of patients with severe acute
brain trauma and intracranial hypertension, Cruz
concluded that continuous monitoring of SjvO2 was
associated with improved outcome . The normal average
of the SjvO2, in a normal awake subject, is 62% with a
range of 55% to 71%. A sustained jugular venous
desaturation of < 50% is the threshold of cerebral ischemia
and for treatment . SjvO2 monitoring can detect
clinically occult episodes of cerebral ischemia, allowing
the prevention of these episodes by simple adjustment
of treatment. In TBI, jugular venous desaturation is
mostly related to CBF reduction secondary to decreased
CPP (hypotension, intracranial hypertension, and
vasospasm) or hypocapnia-associated cerebral
vasoconstriction. Studies showed that a sustained reduction of the
SjvO2 < 50% was associated with poor outcome, and an
independent risk factor for poor prognosis [34-37].
Consequently, SjvO2 monitoring is essential for adjustment
of ventilation during the medical treatment of an
established intracranial hypertension. However, the benefit of
SjvO2 monitoring on severe TBI patients outcomes has
not been confirmed in a RCT.
Brain tissue oxygen tension
Both SjvO2 and brain tissue oxygen tension (PbtO2)
monitoring measure cerebral oxygenation, however,
SjvO2 measures global cerebral oxygenation and PbtO2
measures focal cerebral oxygenation using an invasive
probe (Licox). Rosenthal et al. documented that,
measurements of PbtO2 represent the product of CBF and
the cerebral arteriovenous oxygen tension difference
rather than a direct measurement of total oxygen
delivery or cerebral oxygen . As PbtO2 provides a highly
focal measurement, it is mainly used to monitor
oxygenation of a critically perfused brain tissue. PbtO2 is the
most reliable technique to monitor focal cerebral
oxygenation in order to prevent episodes of desatuartion.
However, global cerebral oxygenation alterations may
not be observed. The normal PbtO2 ranges between 35
mm Hg and 50 mm Hg . A value of a PbtO2 < 15
mm Hg is considered a threshold for focal cerebral
ischemia and treatment . Several studies
demonstrated that PbtO2-based therapy may be associated with
reduced patient mortality and improved patient outcome
after severe TBI [40-42]. In a recent systematic review,
available medical literature was reviewed to examine
whether PbtO2-based therapy is associated with
improved patient outcome after severe TBI . Among
patients who received PbtO2-based therapy, 38.8% had
unfavorable and 61.2% had a favorable outcome. Among
the patients who received ICP/CPP-based therapy 58.1%
had unfavorable and 41.9% had a favorable outcome.
Overall PbtO2-based therapy was associated with
favorable outcome (OR = 2.1; 95% CI = 1.4-3.1). These
results suggested that combined ICP/CPP- and
PbtO2based therapy is associated with better outcome after
severe TBI than ICP/CPP-based therapy alone .
Oddo et al. reported that brain hypoxia or reduced
PbtO2 is an independent outcome predictor and is
associated with poor short-term outcome after severe TBI
independently of elevated ICP, low CPP, and injury
severity. PbtO2 may be an important therapeutic target
after severe TBI . PbtO2 has been documented to be
superior to SjvO2, near infrared spectroscopy , and
regional transcranial oxygen saturation  in detecting
cerebral ischemia. PbtO2 monitoring is a promising, safe
and clinically applicable method in severe TBI patients;
however, it is neither widely used nor available. The
combinations of ICP/PbtO2 intra-parenchymal
monitoring are important and helpful modalities in the
management of severe TBI.
Cerebral microdialysis (MD) is a recently developed
invasive laboratory device, bedside monitor to analyze
brain tissue biochemistry . Usually, a MD catheter is
inserted in susceptible brain tissue to measure
biochemical changes in the area of brain most vulnerable
to secondary insults. Different assays are available to
measure dialysate concentrations including glucose,
lactate, pyruvate, glycerol, and glutamate.
Characteristically, cerebral hypoxia or ischemia results
in a significant increase in the lactate: pyruvate ratio
(LPR) . A LPR > 20-25 is considered a threshold for
cerebral ischemia and is associated with poor outcome
in TBI . Although, MD is a well-established tool
that provides additional assistance in the management
of patients with severe TBI, its use is very limited.
Transcranial Doppler Ultrasonography
Transcranial Doppler (TCD) is a non-invasive method
to measure CBF velocity. It is increasingly utilized in
neurocritical care including TBI. It is a clinically useful
tool in the diagnosis of complications that may occur in
patients with TBI such as vasospasm, critical elevations
of ICP and decreases in CPP, carotid dissection, and
cerebral circulatory arrest (brain death). TCD can
predict post-traumatic vasospasm prior to its clinical
manifestations. Since ICP monitoring is an invasive
procedure with potential risk of associated
complications, TCD has been suggested as a non-invasive
alternative technique for assessment of ICP and CPP [50,51].
The overall sensitivity of TCD for confirming brain
death is 75% to 88%, and the overall specificity is 98%
[52,53]. Although, TCD is an established monitoring
modality in neurocritical care, evidence to support its
regular use for ICP/CPP management in severe TBI
patients is lacking.
Electroencephalogram (EEG) is a clinically useful tool
for monitoring the depth of coma, detecting
non-convulsive (sub-clinical) seizures or seizures activity in
pharmacologically paralyzed patients, and diagnosing
brain death [54,55]. Continuous EEG has been suggested
for the diagnosis of post-traumatic seizures (PTS) in
patients with TBI, especially in those who are receiving
Sensory-evoked potentials (SEP) can yield data on
current brain function in very severe TBI patients; however,
their use is very limited in the initial management of
Near infrared spectroscopy
Near infrared spectroscopy (NIRS) is a continuous,
direct, and non-invasive monitor of cerebral oxygenation
and cerebral blood volume (CBV). In cerebral tissue, the
two main chromophores (light-absorbing compounds)
are hemoglobin (Hb) and cytochrome oxidase. NIRS is
based on the differential absorption properties of these
chromophores in the NIR range, i.e., between 700 and
1,000 nm. At 760 nm, Hb occurs primarily in the
deoxygenated state (deoxyHb), whereas at 850 nm, it occurs
in the oxygenated state (oxyHb). Hence, by monitoring
the difference in absorbency between these two
wavelengths, the degree of tissue deoxygenation can be
In comparison with the SjvO2, NIRS is less accurate in
determining cerebral oxygenation . Although, NIRS
is an evolving technology and a potential as a clinical
tool for bedside cerebral oxygenation and CBF
measurements, its use in neurocritical care remains very limited.
After head trauma, a temperature gradient in brain
temperature compared with body temperature of up to 3C
higher in the brain has been reported. Elevated
temperature is a common secondary systemic insult to the
injured brain. Both invasive (The new Licox PMO:
Integra LifeSciences, Plainsboro, NJ)  and non-invasive
, continuous cerebral temperature monitoring
devices are commercially available for measuring the
brain temperature. However, brain temperature
monitoring is still not widely used during neurocritical care
of patients with severe TBI.
Critical Care Management
Guidelines for the management of severe TBI are widely
available and should constitute the main background
and cornerstone for the development of institutional
clinical practice guidelines-based management protocols.
Several studies have demonstrated the importance and
the impact of implementation of such protocols on the
outcomes of patients with severe TBI [5-7]. We reported
that the utilization of a clinical practice guidelines-based
protocol for severe TBI was associated with a significant
reduction in both ICU and hospital mortalities .
Analgesia, sedation and paralysis
In severe TBI patients, endotracheal intubation,
mechanical ventilation, trauma, surgical interventions (if
any), nursing care and ICU procedures are potential
causes of pain. Narcotics, such as morphine, fentanyl
and remifentanil, should be considered first line therapy
since they provide analgesia, mild sedation and
depression of airway reflexes (cough) which all required in
intubated and mechanically ventilated patients.
Administration of narcotics is either as continuous infusions or
as intermittent boluses.
Adequate sedation potentiates analgesics; provides
anxiolysis; limits elevations of ICP related to agitation,
discomfort, cough or pain; facilitates nursing care and
mechanical ventilation; decrease O2 consumption,
CMRO2, and CO2 production; improves patient comfort;
and prevents harmful movements. The ideal sedative for
TBI patient would be rapid in onset and offset, easily
titrated to effect, and lack active metabolites. It would
be anticonvulsant, able to lower ICP and CMRO2, and
to preserve the neurologic examination. Finally, it would
lack deleterious cardiovascular effects. No commonly
used sedative is ideal. Propofol is the hypnotic of choice
in patients with an acute neurologic insult, as it is easily
titratable and rapidly reversible once discontinued.
These properties permit predictable sedation yet allow
for periodic neurologic evaluation of the patient.
However, propofol should be avoided in hypotensive or
hypovolemic patients because of its deleterious
hemodynamic effects. Moreover, propofol infusion syndrome
(rhabdomyolysis, metabolic acidosis, renal failure, and
bradycardia) is a potential complication of prolonged
infusions or high doses of propofol administration.
Benzodiazepines such as midazolam and lorazepam are
recommended as continuous infusion or intermittent
boluses. In addition to sedation, they provide amnesia
and anticonvulsive effect. Prolonged infusion, high dose,
presence of renal or hepatic failure, and old age are risk
factors for accumulation and oversedation.
Routine use of neuromuscular blocking agents
(NMBAs) to paralyze patients with TBI is not
recommended. NMBAs reduce elevated ICP and should be
considered as second line therapy for refractory
intracranial hypertension. However, the use of a NMBA is
associated with increased risk of pneumonia and ICU length
of stay (LOS), and with neuromuscular complications.
Patients with severe TBI are usually intubated and
mechanically ventilated. Hypoxia, defined as O2
saturation < 90%, or PaO2 < 60 mm Hg, should be avoided
. Prophylactic hyperventilation to a PaCO2 < 25 mm
Hg is not recommended . Within the first 24 hours
following severe TBI, hyperventilation should be
avoided, as it can further compromise an already
critically reduced cerebral perfusion. Coles et al. reported
that, in patients with TBI, hyperventilation increases the
volume of severely hypoperfused tissue within the
injured brain, despite improvements in CPP and ICP.
These reductions in regional cerebral perfusion may
represent regions of potentially ischemic brain tissue
. Excessive and prolonged hyperventilation results in
cerebral vasoconstriction and ischemia. Thus,
hyperventilation is recommended only as a temporizing measure
to reduce an elevated ICP. A brief period (15-30
minutes) of hyperventilation, to a PaCO2 30-35 mm Hg is
recommended to treat acute neurological deterioration
reflecting increased ICP. Longer periods of
hyperventilation might be required for intracranial hypertension
refractory to all treatments including sedation,
paralytics, CSF drainage, hypertonic saline solutions (HSSs)
and osmotic diuretics. However, when hyperventilation
is used, SjvO2 or PbtO2 measurements are
recommended to monitor cerebral oxygenation and avoid
The ventilatory settings should be adjusted to
maintain a pulse oximetry (SpO2) of 95% or greater and/or
PaO2 of 80 mm Hg or greater and to achieve
normoventilation (eucapnia) with PaCO2 of 35 to 40 mm Hg.
Mascia et al. reported that high tidal volume ventilation
is an independent predictor and associated with acute
lung injury (ALI) in patients with severe TBI .
Hence, protective ventilation with low tidal volume and
moderate positive end-expiratory pressure (PEEP) has
been recommended to prevent ventilator-associated lung
injury and increased ICP .
Prior to suctioning the patient through the
endotracheal tube (ETT), preoxygenation with a fraction of
inspired oxygen (FiO2) = 1.0, and administration of
additional sedation are recommended to avoid
desaturation and sudden increase in the ICP. Suctioning ETT
must be brief and atraumatic.
It has been suggested that PEEP increases
intrathoracic pressure leading to a decrease in cerebral venous
drainage and consequently to an increase in CBV and
ICP. However, the effect of PEEP on ICP is significant
only with level of PEEP higher than 15 cm H2O in
hypovolemic patients. Nevertheless, the lowest level of
PEEP, usually 5 to 8 cm H2O that maintains adequate
oxygenation and prevents end-expiratory collapse,
should be used. Higher PEEP, up to 15 cm H2O, may be
used in cases of refractory hypoxemia.
A significant number of patients with severe TBI
develop ALI or acute respiratory distress syndrome
(ARDS), with an incidence of ALI/ARDS reported
between 10% and 30% [62-64]. Etiology of ALI/ARDS in
patients with severe TBI include aspiration, pneumonia,
pulmonary contusion, massive blood transfusion,
transfusion-related ALI (TRALI), sepsis, neurogenic
pulmonary edema and use of high tidal volume and high
respiratory rate [65,66]. Development of ALI/ARDS in
patients with severe TBI is associated with longer ICU
LOS and fewer ventilation free days . Ventilatory
management of patients with severe TBI and ALI/ARDS
is challenging. A balanced ventilation strategy, between
the guidelines for severe TBI or the historical brain
injury approach (adequate oxygenation: optimizing
oxygenation-preserving cerebral venous drainage by using
low levels of PEEP, and mild hypocapnia by using high
tidal volume), and the lung protective ventilation
strategy (by using high PEEP and low tidal volume), is
desired, however, is difficult to achieve. Permissive
hypercapnia, an acceptable strategy in patients with
ALI/ARDS, should be avoided, if possible, in patients
with severe TBI because of the associated cerebral
vasodilatation, increased CBV and ICP.
Hemodynamic instability is common in patients with
severe TBI. Hypotension, defined as SBP < 90 mm Hg
or MAP < 65 mm Hg, is a frequent and detrimental
secondary systemic brain insult and has been reported to
occur in up to 73% during ICU stay . Studies from
the Traumatic Coma Data Bank (TCDB) documented
that hypotension is a major determinant and an
independent predictor of outcome of severe TBI (68).
Hypotension is significantly associated with increased
mortality following TBI [69-71]. Among predictors of
outcome of TBI, hypotension is the most amenable to
prevention, and should be scrupulously avoided and
It is unlikely that an isolated TBI by itself would cause
hypotension unless the patient has become brain dead.
Intravascular volume depletion due to hemorrhage from
associated injuries such as scalp, neck, vessels, chest,
abdomen, pelvis and extremities, or due to polyuria
secondary to diabetes insipidus, are the most common
causes of hypotension in patients with severe TBI.
Other potential reasons for hypotension in patients with
severe TBI are myocardial contusion resulting in
primary pump failure, and spinal cord injury with spinal
shock (cervical lesions cause total loss of sympathetic
innervation and lead to vasovagal hypotension and
bradyarrythmias). An often missed cause of hypotension in
patients with TBI is the use of etomidate for intubation.
It has been reported that even a single dose of
etomidate may cause adrenal insufficiency resulting in
Appropriately aggressive fluid administration to
achieve adequate intravascular volume is the first step in
resuscitating a patient with hypotension following severe
TBI. The CVP may be used to guide fluid management
and is recommended to be maintained at 8 - 10 mm
Hg. In patients who respond poorly to adequate volume
expansion and vasopressors, demonstrate hemodynamic
instability, or have underlying cardiovascular disease, a
pulmonary artery catheter or non-invasive hemodynamic
monitoring may be considered. The pulmonary capillary
wedge pressure should be maintained at 12 - 15 mm
Hg. Several reliable predictors of fluid responsiveness
such as pulse pressure variation, systolic pressure
variation, stroke volume variation, and collapse of inferior
vena cava have been suggested to guide fluid
management. Isotonic crystalloids, specifically normal saline
(NS) solution are the fluid of choice for fluid
resuscitation and volume replacement. HSSs are effective for
blood pressure restoration in hemorrhagic shock;
however, with no survival benefit . The National Heart,
Lung, and Blood Institute of the National Institutes of
Health has stopped enrollment into a clinical trial
testing the effects of HSSs on patients with severe TBI
because HSS was no better than the standard treatment
of NS . Blood and blood products may be used as
Anemia is a common secondary systemic brain insult
and should be avoided, with a targeted hemoglobin
100 g/L or hematocrit 0.30. Brain tissue is reach in
thromboplastin and cerebral damage may cause
coagulopathy . Coagulation abnormalities should be
aggressively corrected with blood products as
appropriate, especially in the presence of a traumatic intracranial
Prior to the insertion of an ICP monitoring, a MAP
80 mm Hg is recommended. The rationale for a MAP
80 mm Hg is to maintain a CPP 60 mm Hg for a
treatment threshold of ICP > 20 mm Hg . Following
the insertion of an ICP monitoring, the management of
MAP will be directed by the ICP/CPP values.
Occasionally, targeted CPP or MAP may not be
achieved despite appropriate fluid resuscitation and
adequate intravascular volume. Excessive and inappropriate
fluid administration to achieve intended CPP or MAP is
associated with fluid overload and ARDS, and should be
avoided. Vasopressors should be used to achieve
targeted CPP or MAP if these could not be obtained with
adequate fluid resuscitation. Norepinephrine, titrated
through a central venous line (CVL), is recommended.
Dopamine causes cerebral vasodilatation and increase
ICP, however, can be used initially via a peripheral
intravenous cannula until a CVL is inserted [76,77].
Phenylephrine, a pure alpha-agonist vasoactive agent, is
recommended in TBI patients with tachycardia. A
recent study reported that patients who received
phenylephrine had higher MAP and CPP than patients who
received dopamine and norepinephrine, respectively
Hypertension, defined as SBP > 160 mm Hg or MAP
> 110 mm Hg, is also a secondary systemic brain insult
that can aggravate vasogenic brain edema and
intracranial hypertension. However, hypertension may be a
physiological response to a reduced cerebral perfusion.
Consequently, and prior to ICP monitoring,
hypertension should not be treated unless a cause has
been excluded or treated, and SBP > 180-200 mm Hg or
MAP > 110-120 mm Hg. Lowering an increased BP, as a
compensatory mechanism to maintain an adequate CPP,
exacerbates cerebral ischemia. Following placement of
an ICP monitoring, the management of MAP is guided
by the CPP.
Cerebral perfusion pressure
Cerebral ischemia is considered the single most
important secondary event affecting outcome following severe
TBI. CPP, defined as the MAP minus ICP, (CPP = MAP
- ICP), below 50 mm Hg should be avoided . A low
CPP may jeopardize regions of the brain with
pre-existing ischemia, and enhancement of CPP may help to
avoid cerebral ischemia. The CPP value to target should
be maintained above the ischemic threshold at a
minimum of 60 mm Hg . Maintenance of a CPP greater
than 60 mmHg is a therapeutic option that may be
associated with a substantial reduction in mortality and
improvement in quality of survival, and is likely to
enhance perfusion to ischemic regions of the brain
following severe TBI. There is no evidence that the
incidence of intracranial hypertension, morbidity, or
mortality is increased by the active maintenance of CPP
above 60 mmHg with normalizing the intravascular
volume or inducing systemic hypertension. Both 60 mm
Hg and 70 mm Hg are cited in the literature as the
threshold above which CPP should be maintained. The
CPP should be maintained at a minimum of 60 mm Hg
in the absence of cerebral ischemia, and at a minimum
of 70 mm Hg in the presence of cerebral ischemia .
PbtO2 monitoring has been suggested to identify
individual optimal CPP . In the absence of cerebral
ischemia, aggressive attempts to maintain CPP above 70 mm
Hg with fluids and vasopressors should be avoided
because of the risk of ARDS .
Mannitol administration is an effective method to
decrease raised ICP after severe TBI . Mannitol
creates a temporary osmotic gradient and it increases the
serum osmolarity to 310 to 320 mOsm/kg H2O. The
prophylactic administration of mannitol is not
recommended . Prior to ICP monitoring, mannitol use
should be restricted to patients with signs of
transtentorial herniation or progressive neurologic deterioration
not attributable to extracranial causes. Arbitrarily,
mannitol should not be administered if serum osmolarity is
> 320 mOsm/kg H2O. Osmotic diuresis should be
compensated by adequate fluid replacement with isotonic
saline solution to maintain euvolmia. The effective dose
is 0.25-1 g/kg, administered intravenously over a period
of 15 to 20 minutes. The regular administration of
mannitol may lead to intravascular dehydration, hypotension,
pre-renal azotemia and hyperkalemia . Mannitol
may pass and accumulate in the brain, causing a reverse
osmotic shift or rebound effect, and raising brain
osmolarity, thus increasing ICP [82,83]. Mannitol is
contraindicated in patients with TBI and renal failure because of
the risk of pulmonary edema and heart failure.
HSSs have been suggested as alternative to mannitol.
HSS has a number of beneficial effects in head-injured
patients, including expansion of intravascular volume,
extraction of water from the intracellular space, decrease
in ICP, and increase in cardiac contractility. HSS
produces osmotic dehydration and viscosity-related cerebral
vasoconstriction. Prolonged administration of a HSS was
associated with lowered ICP, controlled cerebral edema,
with no adverse effects of supraphysiologic
hyperosmolarity such as renal failure, pulmonary edema, or central
pontine demyelination [84,85]. In a recent meta-analysis,
Kamel et al. found that hypertonic saline is more
effective than, and may be superior to the current standard
of care which is, mannitol for the treatment of elevated
Moderate systemic hypothermia at 32C to 34C,
reduces cerebral metabolism and CBV, decreases ICP,
and increases CPP . Evidence of the impact of
moderate hypothermia on the outcome of patients with TBI
was controversial. Initially, studies showed that
moderate hypothermia, established on admission, was
associated with significantly improved outcome at 3 and 6
months after TBI . However, in a large RCT, no
effect of moderate hypothermia has been demonstrated
on outcome after TBI [89,90]. The National Acute Brain
Injury Study: Hypothermia II was a randomized,
multicentre clinical trial of patients with severe TBI who
were enrolled within 2 to 5 hours of injury. Patients
were randomly assigned to hypothermia (cooling to 33
C for 48 hours) or normothermia. There was no
significant difference in outcomes between the hypothermia
and the normothermia groups. The trial did not confirm
the utility of hypothermia as a primary neuroprotective
strategy in severe TBI patients . However,
temperature should be controlled and fever should be
aggressively treated in patients with severe TBI. Moderate
hypothermia may be used in refractory, uncontrolled
Post-traumatic seizures are classified as early occurring
within 7 days of injury, or late occurring after 7 days
following injury . Prophylactic therapy (phenytoin,
carbamazepine, or phenobarbital) is not recommended
for preventing late post-traumatic seizures . However,
the BTF recommended prophylaxis therapy to prevent
early post-traumatic seizure in TBI patients who are at
high risk for seizures . The risk factors include: GCS
score < 10, cortical contusion, depressed skull fracture,
subdural hematoma, epidural hematoma, intracerebral
hematoma, penetrating TBI, and seizures within 24
hours of injury [4,92].
Phenytoin is the recommended drug for the
prophylaxis of early post-traumatic seizures. A loading dose of
15 to 20 mg/kg administered intravenously (I.V.) over
30 minutes followed by 100 mg, I.V., every 8 hours,
titrated to plasma level, for 7 days, is recommended.
Patients receiving antiseizures prophylaxis should be
monitored for potential side effects.
Deep vein thrombosis prophylaxis
Severe TBI patients are at significantly high risk of
developing venous thromoembolic events (VTEs)
including deep vein thrombosis (DVT) and pulmonary
embolism. The risk of developing DVT in the absence of
prophylaxis was estimated to be 20% after severe TBI
Mechanical thromboprophylaxis, including graduated
compression stockings and sequential compression
devices, are recommended unless their use is prevented
by lower extremity injuries. The use of such devices
should be continued until patients are ambulatory. In
the absence of a contraindication, low molecular weight
heparin (LMWH) or low dose unfractionated heparin
should be used in combination with mechanical
prophylaxis. However, the use of pharmacological prophylaxis
is associated with an increased risk for expansion of
intracranial hemorrhage. Although, evidence to support
recommendations regarding the timing of
pharmacological prophylaxis is lacking, most experts suggest initiating
pharmacologic prophylaxis as early as 48 to 72 hours
after the injury, in the absence of other
Stress ulcer prophylaxis
Severe TBI is a well-known risk factor for stress ulcers
(Cushings ulcer) in the ICU. Prophylaxis includes early
enteral feeding, and pharmacological prophylaxis such
as H2- blockers, proton-pump inhibitors and sucralfate
Severe TBI patients are usually in hypermetabolic,
hypercatabolic and hyperglycemic state, with altered G.I.
functions. There is evidence suggesting that
malnutrition increases mortality rate in TBI patients . Studies
documented the superiority of enteral feeding over
parenteral nutrition (PN). Use of PN should be limited to
contraindications of enteral feeding, as it is associated
with complications and an increased mortality .
Hence, early enteral feeding is recommended in patients
with severe TBI, as it is safe, cheap, cost-effective, and
physiologic. The potential advantages of enteral feeding
include stimulation of all gastro-intestinal tract
functions, preservation of the immunological gut barrier
function and intestinal mucosal integrity, and reduction
of infections and septic complications. Frequently,
patients with severe TBI have gastric feeding intolerance
due to many reasons including abnormal gastric
emptying and altered gastric function secondary to increased
ICP, and use of opiates. Prokinetic agents such as
metoclopramide or erythromycin, improve tolerance.
Postpyloric feeding avoids gastric intolerance and allows
higher caloric and nitrogen intake.
Although, the BTF recommended 140% of resting
metabolic expenditure in non-paralyzed patients and
100% in paralyzed patients to be replaced, there is
growing body of evidence suggesting the benefit of a lower
caloric intake [99-102].
In patients with severe TBI, stress hyperglycemia is a
common secondary systemic brain insult. Studies
showed that hyperglycemia has repeatedly been
associated with poor neurological outcome after TBI
[103-108]. Although hyperglycaemia is detrimental,
maintaining low blood glucose levels within tight limits
is controversial in patients with severe TBI, because
hypoglycemia, a common complication of tight glucose
control, can induce and aggravate underlying brain
injury . Vespa et al. reported that intensive insulin
therapy (IIT) results in a net reduction in microdialysis
glucose and an increase in microdialysis glutamate and
lactate/pyruvate ratio without conveying a functional
outcome advantage . Oddo et al. documented that
tight systemic glucose control is associated with reduced
cerebral extracellular glucose availability and increased
prevalence of brain energy crisis, which in turn
correlates with increased mortality. IIT may impair cerebral
glucose metabolism after severe brain injury . A
recent meta-analysis on IIT in brain injury revealed that
IIT did not appear to decrease the risk of in-hospital or
late mortality (RR = 1.04, 95% CI = 0.75, 1.43 and RR =
1.07, 95%CI = 0.91, 1.27 respectively). Moreover, IIT did
not have a protective effect on long-term neurological
outcomes (RR = 1.10, 95% CI = 0.96, 1.27). However,
IIT increased the rate of hypoglycemic episodes (RR =
1.72, 95% CI = 1.20, 2.46) . Consequently, the
majority of currently available clinical evidence does not
support tight glucose control (maintenance of blood
glucose levels below 110-120 mg/dl) during the acute care
of patients with severe TBI .
Steroids administration is not recommended for
improving the outcome or reducing ICP in patients with severe
TBI. Moreover, steroids may be harmful after TBI. The
CRASH trial, a multicentre international collaboration,
aimed to confirm or refute such an effect by recruiting
20000 patients. In May, 2004, the data monitoring
committee disclosed the unmasked results to the steering
committee, which stopped recruitment at 10008
patients. Compared with placebo, the risk of death from
all causes within 2 weeks was higher in the group
allocated corticosteroids (1052 [21.1%] vs. 893 [17.9%]
deaths; relative risk = 1.18 [95% CI = 1.09-1.27]; p =
0.0001). The authors concluded that there was no
reduction in mortality with methylprednisolone in the 2
weeks after head injury. The cause of the rise in risk of
death within 2 weeks was unclear . Hence, in
patients with severe TBI, high-dose methylprednisolone
is contraindicated .
Barbiturate is proven as efficient therapy for refractory
intracranial hypertension. Barbiturates reduce cerebral
metabolism and CBF, and lower ICP . High-dose
barbiturate may be considered in hemodynamically
stable, severe TBI patients with refractory to maximal
medical and surgical ICP lowering therapy. Their main
side effects are: hypotension, especially in volume
depleted patients; and immunosuppression with an
increased infection rate . However, prophylactic
administration of barbiturate to induce burst
suppression EEG is not recommended . Pentobarbital is
recommended for the induction of barbiturate coma as
Pentobarbital: 10 mg/kg over 30 min, then
As alternative, sodium thiopental might be used as
Fluids and electrolytes
The goal of fluid management is to establish and
maintain euvolemia to moderate hypervolemia (CVP = 8 - 10
mm Hg; PCWP = 12 - 15 mm Hg). Negative fluid
balance has been shown to be associated with an adverse
effect on outcome, independent of its relationship to
ICP, MAP, or CPP . Isotonic crystalloids should be
used for fluid management, and normal saline (NS) is
the recommended solution. Aggressive fluid
resuscitation with NS may result in hyperchloremic metabolic
acidosis, a predictable and important consequence of
large-volume, saline-based intravenous fluid
administration, with different clinical implications. Hypotonic
solutions, such as 1/2 NS, NS, Dextrose 5% in water
(D5%W), D5% 1/2 NS, or D5% NS should be avoided.
Ringers lactate solution is slightly hypotonic and is not
preferred for fluid resuscitation in severe TBI patients,
particularly for large volume resuscitation, as it may
decrease serum osmolarity. Glucose containing
solutions, as above or D10%W should be avoided in the
first 24 to 48 hours, unless the patient develops
hypoglycemia in the absence of nutritional support. In addition
to the detrimental effects of hyperglycemia in TBI,
anaerobic cerebral metabolism of glucose produces acidosis
and free water; both would worsen the brain edema.
The use of colloids should be very cautious as it was
reported, in the SAFE trial, to be associated with
increased mortality in patients with TBI . HSSs
have been shown to be effective in decreasing brain
edema, reducing elevated ICP, and increasing MAP and
CPP . Other potential benefits of HSSs include
faster expansion of intravascular volume (with small
volumes), increased cardiac output and pulmonary gas
exchange, reversal of immunomodulation caused by
hypotension, and decreased CSF production. HSS is also
associated with potential side effects including sudden
hypertension, hypernatremia, altered consciousness and
seizures. However, the overall results of HSS related
studies are inconsistent and further clinical trials are
needed to define its role.
In severe TBI patients with increased ICP or brain
edema, a serum sodium level Na+ up to 150 - 155 mEq/
L may be acceptable . However, serum electrolytes
disturbances are common complications after TBI.
Injury to the hypothalamic-pituitary system is a major
contributing factor. The most common causes for
hypernatremia (Na+ > 150 mmol/L) in patients with TBI
are central or neurogenic diabetes insipidus, osmotic
diuresis (mannitol), and the use of HSS. Correction of
severe hypernatremia (Na+ > 160 mmol/L) should be
gradual, as abrupt changes in serum osmolarity and
rapid fall of serum sodium concentration would worsen
cerebral edema. Fluid resuscitation of hypovolemic
hypernatremic TBI patients should be initially only with
NS. Management of electrolytes disturbances should
follow complete volume restoration. Hyponatremia is
detrimental and major secondary systemic brain insult in
patients with severe TBI, as it leads to exacerbation of
brain edema and an increase in ICP. It is usually
secondary to cerebral salt wasting syndrome , or to
the syndrome of inappropriate anti-diuretic hormone
secretion (SIADH). Hypophosphatemia and
hypomagnesemia are common complications in head-injured
patients and they lower the seizure threshold [122,123].
The Lund therapy of severe TBI is based on
physiological principles for cerebral tissue and blood volume
regulation. The therapy aims at preventing cerebral
hypoxia simultaneously with taking measures that
counteract transcapillary filtration. The Lund concept is
more beneficial if the blood brain barrier is disrupted
and more appropriate if pressure autoregulation is lost.
The therapy has two main goals: first to reduce or
prevent an increase in ICP (ICP-targeted goal), and
second to improve perfusion and oxygenation around
contusions (perfusion-targeted goal) by maintaining normal
blood oxygenation, normovolemia and normal
hematocrit. The treatment protocol, to reduce an increased
ICP, includes preservation of a normal colloidal
absorbing force (normal plasma protein concentrations), a
reduction of intracapillary pressure through reduction of
systemic blood pressure by antihypertensive therapy (a
beta1-antagonist, metoprolol, combined with an alpha
2-agonist, clonidine) and a simultaneous, moderate
constriction of precapillary resistance vessels with low-dose
thiopental and dihydroergotamine. A few studies have
reported that Lund therapy was associated with
improved clinical outcome 
General intensive care
Similar to other patients in the intensive care, TBI
victims should receive the usual daily care as follows:
- Raising head of bed to 30 - 45: that would reduce
ICP and improves CPP ; and lower the risk of
ventilator-associated pneumonia (VAP).
- Keeping the head and neck of the patient in a
neutral position: this would improve cerebral venous
drainage and reduce ICP.
- Avoiding compression of internal or external
jugular veins with tight cervical collar or tight tape
fixation of the endotracheal tube that would impede
cerebral venous drainage and result in an increase in
- Turning the patient regularly and frequently with
careful observation of the ICP .
- Providing eye care, mouth and skin hygiene
- Implementing all evidence-based bundles for
prevention of infection including VAP  and central
line bundle .
- Administrating a bowel regimen to avoid
constipation and increase of intra-abdominal pressure and
- Performing physiotherapy
Decompressive craniectomy and hemicraniectomy
Surgical decompressive craniectomy has been suggested
as a promising therapeutic approach for patients with
acute severe TBI at risk to develop severe brain edema.
Decompressive craniectomy and hemicraniectomy, both
are well accepted for the surgical treatment of
intractable intracranial hypertension in cases in which medical
management fails. Decompressive surgery is performed
as a life-saving procedure when death is imminent from
intracranial hypertension. Though the operation is being
increasingly used, evidence regarding its overall effects
on outcomes is contradicting. Albanse et al, in a
retrospective cohort study in 40 patients with intractable
intracranial hypertension and at very high risk of brain
death, decompressive craniectomy allowed 25% of
patients to attain social rehabilitation at 1 yr .
Cooper et al, in a prospective, randomized controlled
trial in 155 adults with severe diffuse TBI and
intracranial hypertension that was refractory to first-tier
therapies, bifrontotemporoparietal decompressive
craniectomy, as compared with standard care, was
associated with decreased intracranial pressure (P < 0.001)
and length of stay in the ICU (P < 0.001), however, with
more unfavorable outcomes (odds ratio = 2.21; 95% CI
= 1.14 - 4.26; P = 0.02). Rates of death at 6 months
were similar in the craniectomy group (19%) and the
standard-care group (18%) .
Predicting outcome after TBI
The early prediction of outcome after TBI is important.
A few predictive models for patient outcomes after
severe TBI have been proposed [131,132]. A relatively
simple prognostic model using 7 predictive baseline
characteristics including age, motor score, pupillary
reactivity, hypoxia, hypotension, computed tomography
classification, and traumatic subarachnoid hemorrhage
has been reported to accurately predict 6-month
outcome in patients with severe or moderate TBI . A
predictive model based on age, absence of light reflex,
presence of extensive subarachnoid hemorrhage, ICP,
and midline shift was shown to have high predictive
value and to be useful for decision making, review of
treatment, and family counseling in case of TBI .
The management of severe TBI centers on meticulous
and comprehensive intensive care that includes
multimodel, protocolized approach involving careful
hemodynamic support, respiratory care, fluid management, and
other aspects of therapy, aimed at preventing secondary
brain insults, maintaining an adequate CPP, and
optimizing cerebral oxygenation. This approach clearly
requires the efforts of a multidisciplinary team including
neurointensivists, neurosurgeons, bedside nurses and
respiratory therapists, and other members of the medical
team. While such management can be challenging, it is
by all means rewarding considering the age of the
victims and the socio-economic impact of the problem.
List of abbreviations
BTF: Brain Trauma Foundation; CBF: Cerebral blood flow; CBV: Cerebral blood
volume; CPP: Cerebral perfusion pressure; CSF: Cerebral spinal fluid; CVP:
Central venous pressure; EEG: Electroencephalogram; GCS: Glasgow coma
scale; HSS: Hypertonic saline solution; ICP: Intracranial pressure; MAP: Mean
arterial pressure; NS: Normal saline; PbtO2: Brain tissue oxygen tension; PEEP:
Positive end expiratory pressure; SBP: Systolic blood pressure; SIADH:
Syndrome of inappropriate anti-diuretic hormone secretion; SjvO2: Jugular
venous oxygen saturation; TBI: Traumatic brain injury.
Samir H. Haddad, MD, is Head Section of Surgical Intensive Care Unit; and
Consultant in the Intensive Care Department at King Abdulaziz Medical City,
Riyadh, Saudi Arabia.
Yaseen M. Arabi, MD, FCCP, FCCM, is Chairman, Intensive Care Department;
and Medical Director, Respiratory Services at King Abdulaziz Medical City,
Riyadh, Saudi Arabia. He is also Associate Professor at College of Medicine,
King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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