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GuidelinesPEML (Paeds Hospital STG)

Traumatic Brain Injury (TBI) And Neuro-Protection In The ICU

Definition Medicine treatment ICD-10 code:  S06.2 DEFINITION Traumatic brain injury (TBI) is a form of Acquired Brain Injury. It is a nondegenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. Se

Definition

Medicine treatment

ICD-10 code: S06.2

DEFINITION

Traumatic brain injury (TBI) is a form of Acquired Brain Injury. It is a nondegenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. Severity of the initial insult is based clinically on the Glascow Coma Scale (GCS): Severe = GCS < 9.

Patients should be referred and managed in a specialised centre

Summarized therapeutic goals – strict avoidance of the 5 ‘H’s.

  • Hypoxaemia
  • Hypotension
  • Hyperthermia
  • Hypoglycaemia
  • Hypercarbia

MEDICINE TREATMENT

Principles for neuroprotection in 1st 24–48 hours.

  1. Airway & Ventilation
    1. Secure the airway.
    2. Optimise oxygenation – Sats > 94% but < 100%.
    3. Use PEEP cautiously – keep PEEP < 10 cmH2O to prevent inhibited venous return – individualise according to patient response. NB: Hypoxia kills neurons.
    4. PaCO2 manipulation
    • Target PaCO2 35–40 mmHg (4.7-6 kPa).
    • Avoid prophylactic hyperventilation PaCO2 < 35 mmHg.
  2. Haemodynamics
    Prevent hypotension
    1. Ensure adequate Cerebral Perfusion Pressure (CPP).
    2. CPP = MAP - ICP
      a. Therefore, placing an ICP monitoring catheter is mandatory, if available.
      b. ICP directed therapy – target MAP to a CPP of 40– 50 mmHg.
    3. If no ICP catheter – target MAP = 65 + 1.5 x age (years).
    4. The use of inotropes and vasopressors should be considered early if needed to achieve the target CPP level.
      Fluids
      1. Optimal fluid resuscitation to ensure normal circulating blood volume.
      2. Use isotonic fluids in patients with raised ICP for fluid resuscitation, e.g. Ringers lactate, normal saline.
      • Avoid hypo-osmolar and dextrose containing IV fluids, e.g. 5% dextrose water, ½ normal saline, in the resuscitation phase of care (see fluid contents table).
        Corticosteroids
        Available evidence does not support the use of corticosteroid.

3. Ongoing management

Analgosedation

Goal is to avoid ICP spikes from restlessness and irritability, especially if ventilated; avoid ventilator/patient dyssynchrony. Objective measures for analgesia and sedation should be used, e.g.: RASS and Comfort score targets.

  • Provide adequate sedation and optimal pain relief to avoid anxiety and pain – helps decrease ICP. See: Pain Control.
  • Morphine/fentanyl and midazolam are the mainstay in the first 24 hours.
  • Titrations or infusions are acceptable.
  • Paracetamol decreases the need for opioids by 30% and is recommended as initial therapy.
  • Avoid NSAID in the 1st 24–48 hours – impaired platelet function may aggravate intracranial bleeding.
  • If above steps are inadequate, consider ketamine and propofol (note – haemodynamic instability may occur and require vasopressor support).
  • Neuromuscular blocking agents are not indicated as routine therapy.

Seizure Prophylaxis

Phenytoin can be considered in patients with severe TBI to reduce the incidence of early onset (< 7 days) post traumatic seizures.

  • Phenytoin, IV, 20 mg/kg over 20 minutes (loading dose) followed by 5–10 mg/kg/day in 3 divided doses (maintenance).

Positioning and care

  1. Optimise venous drainage from the brain:
    • Keep head in neutral position with neck in mid-line.
    • Elevated head of bed – 30 degrees.
    • Remove cervical collars as soon as possible, current prehospital guidelines – hard cervical collar usage is contraindicated.
  2. Limit handling when possible.
  3. Tracheal suctioning:
    • Protection of the brain takes precedence over protection of the lungs.
    • Avoid routine suctioning – a potent elevator of ICP.
    • Suction only if secretions are visible and causing ventilation problems.
    • Do not insert the catheter beyond the end of the ETT or tracheostomy tube.
    • Provide analgosedation and consider neuromuscular blockade with a non-depolarising agent (cisatracurium, vecuronium or rocuronium) when suctioning patients with increased ICP. 
  4. Relieve Abdominal Compartment Syndrome (ACS) if present, as abdominal hypertension increases ICP.

Temperature

  • Maintain normothermia – 36.0–37.5 °C.
  • Hyperthermia > 38 °C must be avoided.
  • Hypothermia – cooling reduces the cerebral metabolic rate of oxygen consumption but published data are controversial.
    ​​​​​​​Targeted temperature management is recommended after prolonged cardiac arrest followed by return of spontaneous circulation.

Feeds

  • Patients with TBI are frequently hyper-metabolic and hypercatabolic.
  • Initiation of early enteral nutrition within 72 hours from time of injury is indicated. Build feeds slowly as tolerated to achieve full enteral nutrition. Avoid nasogastric tubes if a base of skull fracture is suspected.

Stress-ulcer prophylaxis

  • Patients with raised ICP are at high risk for stress ulceration.
  • Consider prophylaxis with a proton pump inhibitor.
  • Stop prophylaxis once feeds have been established.

Glucose 

  • Aim for glucose levels 4–10 mmol/L.

Family Information

  • Allow family contact as this helps calm and reassure the patient.
  • Prepare family with advice on infection control and ICU practices.
  • Commence counseling early in the patient’s stay – regarding high risk of short-term adverse outcomes in patients with TBI and raised ICP requiring ICU, and the likelihood of protracted recovery and permanent disability even in survivors of initial ICU stay.

4. Acute management of raised ICP

  • Controlled hyperventilation (PaCO2 no less than 30 mmHg – risk cerebral vasoconstriction and induced ischaemia) only transiently for management of very acute and serious elevation of intracranial pressure.
  • Osmotic therapy for children with suspected raised ICP (avoid use if sodium > 160 mmol/L).

Hypertonic saline should be considered for acute treatment of TBI with raised ICP (> 20 mmHg).

  • Sodium chloride 5%, IV, 3 mL/kg as a stat dose over 20 minutes.
  • Continuous infusion of sodium chloride 3%, IV, 0.1–1 mL/kg/hour, titrated to maintain ICP < 20 mmHg).

Mannitol can also be used for the treatment of raised ICP, although hypertonic saline has a better efficacy and side effect profile.

  • Mannitol, IV, 0.5–1 g/kg over 10 minutes, may be repeated 6 hourly.
  • Urgent neurosurgical consultation if raised ICP is refractory to medical management.
  • High dose barbiturate therapy in refractory intracranial hypertension.

Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 23: Paediatric Intensive Care,  23.7 Traumatic Brain Injury (TBI) And Neuro-Protection In The ICU

Drugs mentioned

NeoHealth® ID 35230 · updated 5/29/2023