Trauma Care 4: Severe Traumatic Brain Injury—Adult
Protocol for Management of Adult Patients Age 18 and Older
Emergency Department: Resuscitation Phase of Care 1-3
| Parameter | Goal During Resuscitation Phase |
| Neurological Checks | Assess GCS at time of admission to ED (prior to intubation and sedation when possible), at post-resuscitation and as needed in between |
| Oxygenation | Patient to be on 100% FiO2 Goal O2 saturation 100% Goal PaO2 30-35 unless otherwise instructed Avoid hyperventilation unless ICP> 30 mm Hg and/or there are signs of progressive neurological deterioration unresponsive to other measures. Hyperventilate to ICP of 25 mm Hg. Keep PaCO2>25 mm Hg. RSI is preferred method of intubation unless contraindicated. iSTAT ABG for baseline All intubated patients must have an end-tidal CO2 monitor. |
| Blood Pressure Management and Fluid Resuscitation | Goal SBP> 100 mm Hg SBP not to exceed 160 mm Hg MAP > 80 mm Hg until CPP can be measured Maintain pressures with fluids, crystalloid (NS) with colloids and blood products as needed. If fluids unsuccessful, begin norepinephrine 0.01-0.3 mg/kg/min (notify MD for dose > 0.15 mg/kg/min Second option is dopamine 1-15 mg/kg/min |
| Fluid Management | NS unless otherwise instructed No dextrose-containing solutions |
| Electrolyte Management and Hyperosmolar Therapy4 | Begin infusion of 5% Na (Cl:AI) (1:1) 150 mL IV over 15 minutes x1 in patients with neurological deterioration or a CT scan showing tight cisterns of midline shift. May infuse peripherally in a new large vessel site. Change infusion to a central line as soon as possible. |
| Timing of Craniotomy | Any patient who is progressively declining and/or with
symptoms of uncal herniation syndrome, should be taken emergently to the operating room. For example:
|
| CPP Management | Goal > 60-70 mm Hg. Do not exceed 70 mm Hg unless otherwise instructed |
| Glucose Management | Goal range: < 150 mg/dL. No treatment required in the ED unless glucose > 300 mg/dL as risk of hypoglycemia is greater than risk of hyperglycemia |
| Anti-convulsant Therapy5 | Phenytoin load 18 mg/kg IV in NS at a rate of 25 mg/min in central line or secure peripheral line |
| Radiological Imaging | Non-contrast CT scan ASAP |
| Transport | Per hospital policy |
Recommendations for Transfer to a Level 1 Trauma
Center:
We have listed criteria to assist you in determining if your TBI
patient should be transferred to a Level 1 Trauma Center:
- All severe TBI defined as GCS < 8
- Any patient requiring neurosurgical intervention
- Acute intracranial pathology such as hematomas > 1 to 2 cc, compressed basal cisterns, contusions
- Penetrating injury or open fracture of the skull
- Basilar skull fracture with or without CSF leak
- Moderate or mild TBI with abnormal CT findings
- TBI associated with child abuse
Other considerations:
- Carotid or vertebral arterial injury
- Systemic hypotension (systolic BP < 90 mm Hg in adults or BP < age stated norms for children)
- Any patient at the discretion of the referring physician
References
- Management of Severe Traumatic Brain Injury. Brain Trauma Foundation. 3rd ed. May 2007. Available at www.braintrauma.org. Accessed September 7, 2011.
- Guidelines for the Management of Severe Traumatic Brain Injury, 3rd ed. New York, New York: Brain Trauma Foundation, 2007. Available at https://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdf. Accessed September 3, 2010.
- Hennepin County Medical Center Traumatic Brain Injury Center. Available at http://www.hcmc.org/braininjury. Accessed September 3, 2010.
- Hennepin County Medical Center Emergency Department Protocol (Biros, Jancik, and GL Rockswold)
- Hennepin County Medical Center Clinical Therapeutics Manual