ICP ≤ 8 NO surgical lesion Insert ICP Monitor: Ventriculostomy preferred Insert CVP and/or PA catheter as needed Surgical lesion OR Measure CPP Adults ≥ 60 Peds: see chart Continue present care* Sedation – 1st choice propofol (Diprovan) HOB @ 30° Ç Drain EVD Consider Repeat CT ICP >20 and/or CPP below target? ICP >20 and/or CPP below target? Mannitol 1g/kg (1st dose) then 0.5 g/kg Q4h Insert CVP or PA catheter as pt’s status dictates Measure serum osmolarity and Na+, 2 hours after 1st dose then q4h. Hold for osm>320 or Na >155 and call Neurosurgery. Consider repeat CT if no improvement. Continue present care* ICPÈ CPPÇ ICP >20 and/or CPP below target? Insert PA catheter if not already present. Re- assess fluid and cardiac status Begin vasopressors (levophed or neosynephrine). Titrate to CPP >60 ICP >20 and/or CPP below target? Call neurosurgery, consider second tier therapies such a pentobarbital coma or decompressive craniectomy Consider repeat CT scan Continue present care* ICPÈ CPPÇ Continue present care* ICPÈ CPPÇ Examine patient for correctable non-TBI causes of increased ICP or low CPP such as intra-abdominal hypertension, pneumothorax, cardiac failure, cardiac tamponadeor high PEEP *Overall Management Strategies in Patients with Moderate to Severe Traumatic Brain Injury The algorithm provides a sequential and stepwise escalation in the treatment of patients with moderate to severe traumatic brain injury. The following are some general management strategies to decrease morbidity and mortality and improve overall outcome Hypotension has been clearly demonstrated to be an independent predictor or worse outcome following TBI, therefore a primary goal in patient management is judiciously avoid hypotension ensuring adequate volume by: •Transfusing to Hb of 10g/dl in the acute trauma patient •Use FFP as volume if there is any coagulopathy •Use of normal saline is the primary crystalloid solution for the first 24 hours (see further fluid and sodium issues below) •Consider using albumin and/or hypertonic saline for further volume expansion •Early institution of CVP or PA catheter monitoring to better assess volume and cardiac status in patients not responding clearing their lactate or base deficit. Hypoxemia, while not as strongly as hypotension, has also been shown to correlate with a worse neurologic outcome. Thus, the goal in management is to maintain Pa02>90mmHg and O2 saturation >98%. This needs to be accomplished without increasing PCO2 greater than 40mmHg. Fever should be treated to attempt to decrease overall metabolism especially that of the brain. The goal is to maintain temperature ≤ 101°F. Peripheral cooling should NEVER be used without a central acting antipyretic such as acetaminophen Fluids, sodium and osmolarity. Unfortunately, while there is no “off the shelf” optimal fluid to resuscitate the injured brain there are some general concepts to remember. Hypertonic and hypernatremic environments have been shown to be beneficial in the lab and in some clinical trials so the goal is to maintain or increase sodium and osmolarity as needed while maintaining circulating volume. Most importantly, sodium and osmolarity shouldn’t decrease. To accomplish this on should: •Avoid using ANY hyponatremic solutions •Avoid using any solutions containing 5% dextrose (e.g. D5LR, D5NS etc) as they are thought to increase brain metabolism and edema •Use normal saline as the primary crystalloid solution in the initial resuscitation of the brain injured patient •Carefully monitor the volume status and diuresis with mannitol therapy. Do not allow patient to become hypovolemic, but do not over-replace and resuscitate either. Most patients, without significant extra-cerebral injuries will tolerate a one liter initial diurersis. Begin with 50-75% replacement of previous hour’s urinary output with NS until serum sodium and osmolarity begins to rise. •Consider supplementing the resuscitation with 3% saline in those patients with high ICP in whom you want a rapid increase in osmolarity rapidly •Monitor the serum chloride. A small to moderate degree of hyperchloremia may be unavoidable but serum chloride should not rise above 120