Traumatic Brain edema

- Executive Summary

This topic is concerned with diagnosis and treatment guidelines of traumatic brain edema.

➡️Recommendations:

Conservative Management of traumatic brain edema is divided into 4 tiers:

Tier 0

▪️  Head elevation.

o   Strong recommendation

▪️Avoid hypoxia.

o   Strong recommendation.

▪️  Avoid hypotension

o   Strong recommendation.

▪️  Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2 with ICP monitoring.

o   Strong recommendation.

▪️  Brain imaging (CT) must be available and repeated as much as needed. (if not available refer to a tertiary center)

o   Strong recommendation

▪️  We recommend ICU admission and close neurological observation with  CT monitoring for the development and progression of brain stem compression. ( if not available refer to a tertiary center)

o   Strong recommendation.

Tier 1

▪️  We recommend mannitol for control of IC-HTN (within hospitals).

▪️  Intermittent boluses may be more effective than continuous infusion

▪️  Effective doses range from 0.25–1 gm/kg body weight

▪️  Avoid hypotension (SBP < 90mm Hg) which may result from the diuretic effect of mannitol, which can lead to decreased circulating fluid volume

o   Strong recommendation.

▪️  Try to adjust partial pressure of carbon dioxide (PaCO2) at lower ranges of normal val­ues (i.e. 35-38 mmHg).

o   Conditional recommendation.

Tier 2

▪️  Consider the use of neuromus­cular blocking agents (NMBAs).

o   Conditional recommendation

▪️  We recommend targeting a cerebral perfusion pressure (CPP) of 60-70mm Hg

o   Strong recommendation.

▪️  Try to adjust the partial pressure of CO2 at 32-35 mmHg (mild hypocapnia)

o   Conditional recommendation

Tier 3

▪️  High-dose barbiturate therapy may be used for IC-HTN refractory to maximal medical and surgical ICP-lowering therapy. Patients should be hemodynamically stable before and during treatment.

o   Conditional recommendation

▪️  The availability of equipped neurosurgery operating room is essential for management. (if not available refer to a tertiary center)

o   Strong recommendation.

➡️  Surgical Intervention:

▪️  We recommend decompressive craniectomy ± duroplasty for patients with late refractory ICP elevations

o   Strong recommendation

▪️  Timing of surgery: patients meeting surgical criteria should be operated as soon as possible due to the potential for rapid deterioration

o   Strong recommendation.