Traumatic Brain edema

Items:

Strength of Recommendation:

Level of Evidence:

▪️  Head elevation. 

Strong

Moderate quality evidance⁶

▪️ Avoid hypoxia

Strong

Moderate quality evidance⁶

▪️ Avoid hypotension

Strong

Moderate quality evidance⁶

▪️  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

Strong

Moderate quality evidance⁶

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

Strong

Moderate quality evidance⁶

▪️  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)

Strong

Moderate quality evidance⁶

▪️  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

Strong

Moderate quality evidance⁶

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

Conditional

Low quality evidance⁷

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

Conditional

Moderate quality evidance⁶

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

Strong

Moderate quality evidance⁶

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

Conditional

High-Quality Evidence ⁸

▪️  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.

Conditional

High-Quality Evidence ⁸

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

Strong

High-Quality Evidence ⁸

Items:

Strength of Recommendation:

Level of Evidence:

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

Strong

Low quality evidance⁹

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

Strong recommendation.

Low quality evidance¹⁰