Traumatic Brain contusions

Items:

Strength of Recommendations:

Level of evidence

·   Avoid hypoxia

Strong

Moderate quality evidance⁹

·   Avoid hypotension

Strong

Moderate quality evidance⁹

·  Secure the airway (endotracheal intubation) in patients with GCS ≤8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2. (if not available refer to a tertiary center)

Strong

Moderate quality evidance⁹

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

Strong

Moderate quality evidance⁹

·  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 evidance⁹

·  Follow-up head CT scan within 6 to 8 hours following brain injury must be obtained.      (if not available refer to a tertiary center

Strong

Moderate quality evidance⁹

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

Strong

Moderate quality evidance⁹

·  We recommend seizures prophylaxis in patients with frontal and temporal lobe cerebral contusions

Strong

Moderate quality evidance⁹

·  Head elevation and the same measures in the initial management

Strong

Moderate quality evidance⁹

· 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 decrease circulating fluid volume

Strong

Moderate quality evidance⁹

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

Conditional

Low quality evidance⁹

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

Conditional

Moderate quality evidance⁹

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

Strong

High-Quality Evidence ¹⁰

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

Conditional

High-Quality Evidence ¹⁰

· 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 recommendation.

Moderate-Quality Evidence ¹⁰

Items:

Strength of Recommendations:

Level of Evidence:

·   Surgery may be indicated in the following indications:

▪️  Progressive neurological deterioration referable to the TICH, medically refractory IC-HTN

▪️ Signs of mass effect on CT

▪️  TICH volume > 50cm3 cc or ml

▪️  GCS = 6–8 with frontal or temporal TICH volume > 20cm3 with midline shift ≥ 5mm  and/or compressed basal cisterns on CT

Conditional

High-Quality Evidence ¹⁰

·  If the contusion with the surrounding edema cause mass effect according to the site you may do frontopolar lobectomy or tempropolar lobectomy

Conditional

High-Quality Evidence ¹⁰

·  If the hemorrhagic contusion coalesced to form intracerebral hematoma you may do evacuation

Conditional

High-Quality Evidence ¹⁰

·  Decompressive craniectomy with duroplasty may be indicated in cases in which the usual mechanisms to reduce the ICP are uneffective

Conditional

High-Quality Evidence ¹⁰