Guidelines

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

• Hyperosmolar Therapy
  • Hyperosmolar therapy can lower intracranial pressure, but evidence for effects on clinical outcomes is insufficient for a specific recommendation.
• Anesthetics, Analgesics, and Sedatives
  • No strong recommendation for barbiturates to prevent intracranial hypertension.
  • High-dose barbiturate therapy is recommended for controlling elevated ICP refractory to maximum medical and surgical treatment.
  • Propofol can control ICP but is not recommended for improving mortality or outcomes over 6 months.
• Steroids
  • Steroids are not recommended for improving outcomes or reducing ICP in severe TBI patients; high-dose methylprednisolone is associated with increased mortality.
• Seizure Prophylaxis
  • Insufficient evidence to support a strong recommendation for seizure prophylaxis.
  • Prophylactic use of phenytoin or valproate for late post-traumatic seizures is not recommended.
  • Phenytoin is recommended to decrease the incidence of early post-traumatic seizures when benefits outweigh the risks.
• Blood Pressure Thresholds
  • Maintaining systolic blood pressure (SBP) at ≥100 mm Hg for specific age groups may decrease mortality and improve outcomes.
• Intracranial Pressure Thresholds
  • Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality.
  • A combination of ICP values and CT findings should guide management decisions.
• Cerebral Perfusion Pressure Thresholds
  • Target cerebral perfusion pressure (CPP) for survival and favorable outcomes is recommended between 60 and 70 mm Hg.
  • Avoid aggressive attempts to maintain CPP above 70 mm Hg due to risks of adult respiratory failure

Landmark Studies

Corticosteroid randomisation after significant head injury (CRASH -1) Trial

• The CRASH trial was another large, randomized, placebo-controlled trial that assessed the effect of steroids on mortality and neurological outcomes in patients with moderate to severe TBI. The trial enrolled 10,008 patients from 21 countries who were within 8 hours of injury and had a GCS of 12 or lower and an indication for intracranial pressure (ICP) monitoring. The primary outcome was the proportion of patients with an unfavorable outcome, defined as a Glasgow Outcome Scale-Extended (GOSE) score of 4 or lower, at 6 months. The main finding was that steroids did not improve outcomes in patients with moderate to severe TBI and increased the risk of adverse events, such as infections, gastrointestinal bleeding, and hyperglycemia. The results were consistent across different subgroups, including time to treatment, baseline GCS, and presence of intracranial hypertension. The authors concluded that steroids should not be used routinely in patients with moderate to severe TBI.

CRASH- 3 Trial

• The CRASH-3 trial was a large, randomized, placebo-controlled trial that evaluated the effect of tranexamic acid (TXA) on death and disability in patients with traumatic brain injury (TBI). The trial included 12,737 patients from 29 countries who were within 3 hours of injury and had a Glasgow Coma Scale (GCS) of 12 or lower or any intracranial bleeding on CT scan. The primary outcome was head injury-related death in the hospital within 28 days of injury. The main finding was that TXA reduced head injury-related death in patients with mild to moderate TBI (GCS 9-12) but not in those with severe TBI (GCS 3-8). The benefit was greatest in patients treated within the first hour of injury and declined with increasing time to treatment. There was no evidence of increased risk of adverse events, such as vascular occlusive events, seizures, or infections, associated with TXA.