Severe TBI

TBI Management  Guideline

Neurologic Monitoring:

• Clinical – obtain baseline neurologic examination and Glasgow Coma Scale score (GCS) before sedation and muscle relaxants are administered
• Routine nursing neurovitals assessment hourly

Spinal precautions:

• Head of bed elevated 20-30° with head in neutral midline position, maintaining spinal precautions
• Semi-rigid cervical collar (Aspen) maintained until cervical spine cleared

Hemodynamic support:

• Maintain mean arterial pressure upper end of normal based on normal age range

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• Inotropes as required/fluids as required

Ventilation & Oxygenation:

• Maintain PaCO2 35 to 40 mmHg
• Wean FiO2 to maintain arterial saturations >94%

Fluid and electrolytes monitoring:

• All patients with brain injury (anoxic or traumatic) are at risk for disordered sodium regulation
• Early detection of sodium abnormalities is essential to maintaining serum sodium within target range and preventing secondary brain injury.
• D5W 0.9%NaCl at 70% maintenance
• Foley catheter and hourly urine output measurement for 48 hours
• Monitor serum electrolytes and blood gases every 6 hours for 48 hours – serum Na to maintain 140 or above
• Initial labs should include liver “function” and coagulation screen
• Maintain serum glucose 5-8mmol/L
• Notify PICU physician if urine output is < 0.5 mL/kg/hour, > 4 mL/kg/hour in a single hour, or > 2.5 mL/kg/hour for more than three hours

Temperature control:

• Monitor core temperature - esophageal (if available)
• Regular acetaminophen 15mg/kg NG/NJ every 6 hours – review every 24 hours
• Normothermia 36-36.8°C
• Consider neuromuscular blockade to facilitate temperature control

Sedation/analgesia:

• Initiate analgesia and sedation with morphine infusion 10-40 mcg/kg/hour and midazolam
  infusion 50-150 mcg/kg/hour

Seizure prevention:

• Prophylactic levetiracetam (Keppra®) 10mg/kg NG/PO every 12 hours for 7 days
• For clinical seizures, give a loading dose of levetiracetam (60mg/kg IV)
• Consider EEG within first 36 hours of admission
• Continuous EEG monitoring is recommended if resources are available