Book
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.
