Disclaimer
These guidelines are intended to provide a framework for the clinical
care of adult critically ill patients admitted within the University of
Kentucky Healthcare Enterprise. These guidelines do not dictate an exclusive
course of treatment or procedure to be followed and should not be construed as
excluding other acceptable methods of practice and are not a substitute for sound
clinical judgement.
Traumatic brain injury (TBI) is a major cause
of morbidity and mortality in Kentucky as well as worldwide. In the fiscal year
2024-2025, 1084 patients with traumatic head injury were admitted to UK, with 160
of those patients sustaining severe TBI (defined by Glasgow Coma Scale (GCS) ≤
8). Effective management requires a systems-based approach to optimize
intracranial pressure (ICP), cerebral perfusion, and systemic physiology, with
the goal of optimizing mortality and neurological outcomes. These guidelines
incorporate evidence-based recommendations from the Brain Trauma Foundation
(BTF)1, American College of
Surgeons (ACS) Best Practices Guidelines2, Neurocritical Care
Society (NCS), Society of Critical Care Medicine (SCCM), and pertinent clinical
data to standardize care delivery for patients with severe and moderate TBI.
Purpose
To establish a standardized,
evidence-based approach to the management of severe (GCS ≤8)
and moderate (GCS 9-12) TBI patients in the critical care setting, with the
goal of reducing secondary brain injury, optimizing survival, and improving
long-term functional outcomes.
Guideline or Protocol
Primary Outcome Measure
The primary goal of these guidelines is to reduce
the in-hospital mortality and improve functional outcomes of severe and
moderate TBI patients.
Guideline or Protocol Statements
The following guidelines are reported in a critical
care systems-based fashion. These guidelines incorporate recommendations from
the BTF1,
ACS2, NCS,
SCCM, and Seattle International Severe Traumatic Brain Injury Consensus
Conference (SIBICC)3.
Neurological Management
·
Positioning: Head of bed
elevated >30–45°, head midline, remove c-collar if able.
·
Sedation &
Analgesia: Propofol, midazolam, ketamine, dexmedetomidine;
opioids and multi-modal pain regimen for analgesia.
·
Monitoring:
o
Hourly neuro
checks (plus pupillometry if available). If having problems with
intracranial hypertension, do not hold sedation for neuro checks and instead
perform pupillometry only. If having elevated intracranial hypertension and no
pupillometer is available, do not hold sedation for neuro checks and instead
check pupillary light reflex only.
§
If sedation is
not held for neuro checks due to intracranial hypertension, the neurosurgery
team must be notified that full neuro checks are not being performed given this
concern.
§
Resuming neuro
checks with sedation held should be first discussed with the ICU attending and the
treating neurosurgeon.
o
ICP monitor should be
placed if GCS ≤8 with abnormal head CT.
§
ICP monitor
should be placed in salvageable patients with GCS ≤8 with normal
HCT if at least 2 of the following are present:
·
1) Age >40 yo
·
2) Unilateral/Bilateral
motor posturing
·
3) SBP <90
mmHg
§
Method of ICP
monitoring (external ventricular drain (EVD), parenchymal monitor, etc) is up
to the discretion of the treating neurosurgeon.
§
Placement of
brain tissue oxygen monitor is up to the discretion of the treating
neurosurgeon (at the time of the writing of these guidelines, brain tissue
oxygen monitoring is not currently standard of care).
§
Post-placement head
CT should be obtained within 1 hour unless patient is too unstable for
transport.
o
Consider continuous
EEG (cEEG) to monitor for non-convulsive seizures if etiology of depressed
consciousness is unclear or could be attributed to seizures (typical duration of
cEEG is 2-3 days, endpoint to be determined by the neurology team).
o
Consider daily transcranial
dopplers (TCDs) if new neurologic deficit or if concerned for post-traumatic
vasospasm; this should be discussed with neurosurgery.
·
Goal Brain
Perfusion Parameters:
o
ICP 22 mmHg (abnormal is
>22 mmHg for ≥5 minutes without stimulation)
§
* 22 mmHg is
equal to 30 cm H2O *
o Cerebral perfusion pressure (CPP) 60-70 mmHg
o
Brain tissue oxygen
partial pressure (PbtO2) ≥20 mmHg (if brain tissue oximetry is
available). Abnormal PbO2 is <20 mmHg for ≥5 minutes without stimulation.
·
Repeat Imaging: Head CT at 4-6
hours after initial CT to evaluate for stability of intracranial lesion. Obtain
CTA head & neck for screening for blunt cerebrovascular injury (BCVI)
if not yet completed.
·
Seizure
Prophylaxis: Levetiracetam for 7 days (loading dose 30 mg/kg with
maintenance dose 1 g q12h, will adjust for renal function) unless indication to
continue.
o
Indications
for prophylaxis: Severe or moderate TBI with intracranial hematoma
and/or cortical contusion, depressed skull fracture, penetrating TBI. Mild TBI (GCS
13-15) does not require seizure prophylaxis regardless of the pattern of
intracranial blood (no evidence to prevent early seizures or later onset
epilepsy).
·
Elevated ICP /
Refractory Intracranial Hypertension Management:
o
General
principles (see SIBICC algorithm3, Figures
1 & 2, for details):
§
Place ICP monitor
as per guidance above.
§
Treat ICP if >22
mmHg or 30 cmH2O for ≥5 minutes without stimulation.
§
Hypertonic
therapy boluses are indicated for either documented intracranial
hypertension or signs/symptoms suspected to be due to mass effect (i.e.,
“blown” pupil, herniation syndrome).
§
Consider external
ventricular drain (EVD) for CSF drainage for refractory ICP if one is not
already in place.
§
Consider
neuromuscular paralysis.
§
Consider
barbiturate coma.
§
SIBICC algorithm3 details a
tiered approach to ICP management.
o
Recommend
against continuous hyperosmolar therapy (i.e.,
continuous infusion of hypertonic saline), with no evidence of benefit3,4. If hyperosmolar
therapy is required, bolus dosing should be given.
o
Recommend
against sodium goals targeting mild hypernatremia due to no evidence of
benefit and evidence of possible harm5–8.
o
Surgical
decompression for ICP management is considered third-line salvage
therapy3,9,10.
§
Following
surgical decompression, de-escalation of medical maneuvers (i.e., hyperosmolar
therapy, sedation, paralysis, barbiturates) should not occur for at least 24
hours, and must be discussed with the neurosurgery team prior to initiating de-escalation.
o
In non-surgically
decompressed patients, de-escalation of intracranial hypertension management,
including decreasing sedation, paralysis, barbiturates, removal of ICP monitor,
etc., should follow the SIBICC algorithm and be discussed with neurosurgery.
Cardiovascular Management
·
General Blood
Pressure Goal: SBP 110–160 mmHg.
o
If patient has an
ICP monitor, BP/pressors should be titrated to CPP goals rather than SBP goals.
If patient has an ICP monitor, do not fixate on strict BP goals – focus instead
on CPP and brain perfusion.
o
In the absence of
an ICP monitor, the upper limit of the SBP goal in TBI is debated in the
literature. Best available evidence suggests SBP 110 as a lower limit and SBP
160 as an upper limit11–13.
·
Start propranolol
(20 mg PO q12h with BP & HR hold parameters; can start 1 mg IV q6h if there
is no enteral access) within 24-48h if hemodynamics permit due to potential
mortality benefit14,15.
Respiratory Management
·
Goal Parameters:
o
SpO2
≥94%
o
PaO2
80–200 mmHg
o
PaCO2
35–45 mmHg
o
pH 7.35-7.45
·
Prophylactic hyperventilation
(PaCO₂ ≤25 mmHg) is discouraged in the first 24 hours,
unless done briefly as a temporizing measure and only if it is coupled with
either SjvO₂ or PbtO₂.
·
Initiate end-tidal
CO2 monitoring, but if hypocapneic on monitor, confirm via ABG
before changing ventilator settings.
·
Consider tracheostomy
by day 7 if prolonged ventilation is expected.
Gastrointestinal Management
·
Start enteral
feeding as soon as able, either via gastric or post-pyloric feeding.
Post-pyloric feeding is preferred, but do not delay nutrition waiting for a
post-pyloric feeding tube.
·
Proton pump
inhibitor (PPI) for GI prophylaxis. Use H2 receptor antagonist (H2RA) if unable
to use PPI.
Genitourinary & Electrolyte Management
·
Insert
temperature-sensing Foley catheter.
·
Maintain
normovolemia.
·
Avoid giving
albumin due to risk of increased mortality16.
·
Maintain serum
sodium 135–145 mmol/L (as per Neuro management, avoid prophylactic
targeting of hypernatremia). If getting hypertonic therapy for intracranial
hypertension, ideally maintain Na <160 mmol/L.
·
Maintain serum
osmolality ≤320 mOsm, though this may rise if receiving hypertonic therapy.
·
If serum Na >160
mmol/L or osmolality >320 mOsm, consider moving to the next tier of therapy
for management of intracranial hypertension3.
Infectious Disease & Temperature
Management
·
Targeted Temperature
Management (TTM): Goal temperature 36.5–37.5°C.
o
Schedule
acetaminophen at admission.
o
Turn on cooling
device(s) (cooling blanket, Arctic Sun, and/or intravascular cooling device)
when temperature approaches 37.5°C to prevent hyperthermia. Given the
high prevalence of fever in severe TBI and its association with poorer
outcomes, start TTM prior to any fever.
·
Shivering Management:
acetaminophen, dexmedetomidine, magnesium sulfate, buspirone, skin counterwarming
(place hot packs on hands and feet while cooling the body)17.
·
Prophylactic antibiotics are not
indicated for: presence of ICP monitor or EVD, CSF leaks, skull base fractures,
pneumocephalus.
Hematologic Management
·
Goal
Parameters:
o
INR ≤1.6
o
PTT in normal
range
o
Hb ≥7 gm/dL (unless
having intracranial hypertension and on a higher tier per SIBICC algorithm3)
o
Platelets ≥80,000/mm3
·
Check TEG and
correct coagulopathy.
·
Reverse
anticoagulants if last dose was within the past 24h or if anti-Xa
(apixaban or rivaroxaban), PTT (dabigatran), or INR (warfarin) are elevated.
·
Consider giving desmopressin
if confirmed or suspected anti-platelet use within the past 7 days, or if
uremic (0.4 mcg/kg IV desmopressin)18.
·
Do not give
empiric platelets unless platelets <80,000/mm3 or patient
is going for surgery with neurosurgery (1u platelets and/or 0.4 mcg/kg IV
desmopressin).
o
Platelet
administration in the absence of a strong indication for transfusion has no
evidence of benefit with evidence of possible harm19–22.
Endocrine Management
·
Goal blood glucose
80–180 mg/dL.
·
Avoid
dextrose-containing IVF (due to concern for worsened cerebral edema) unless
patient has documented hypoglycemia. Prior to initiating dextrose-containing
IVF, first attempt goal tube feeds and amps of D50 three times. If
dextrose-containing IVFs are ultimately started, they should be stopped as soon
as patient’s hypoglycemia is controlled.
·
Avoid
corticosteroids for treatment of cerebral edema in TBI due to a slightly
increased risk of mortality23. However, if
a strong indication for steroids exists (i.e., severe ARDS, severe COPD, refractory
shock), consider giving steroids if the benefits outweigh the risks.
Musculoskeletal Management
·
Pressure ulcer
prevention strategies.
Prophylaxis
·
DVT
prophylaxis: Initiate VTE prophylaxis 24 hours after initial
injury if repeat head CT is stable. If repeat head CT is not stable,
initiate VTE prophylaxis 24 hours after the stable head CT. If patient
is post-op or if there is any uncertainty about prophylaxis, discuss with
neurosurgery.
·
GI prophylaxis: Initiate
PPI (i.e., pantoprazole). Stop GI prophylaxis when patient is no longer
mechanically ventilated or coagulopathic, and enteral feeding is established.
Indications for Early (<4h) Surgical
Decompression (based on the BTF Guidelines1)
·
Epidural hematoma (EDH): >30 cm3, any EDH with GCS
<9 and anisocoria, neurologic decline.
o
If
<30 cm3 and <15mm thick and <5 mm midline shift (MLS)
without focal deficit, can be managed with close observation.
·
Subdural hematoma (SDH): >10 mm thick or MLS >5 mm.
o
If
GCS <9 and SDH <10 mm and MLS <5 mm, proceed with surgical evacuation
if GCS decreased by 2+ points between injury and admission, or patient has
asymmetric or fixed or dilated pupils, or if ICP >20 mmHg.
·
Traumatic parenchymal lesions: GCS 6-8 with frontal or temporal
contusions >20 cm3 with MLS ≥5 mm and/or cisternal compression,
or any superficial lesion >50 cm3, or neurologic decline
attributable to the hematoma.
·
Posterior fossa mass lesions: lesions with mass effect (4th
ventricle, cisterns, etc.), GCS <13, neurological deterioration.
·
Depressed skull fractures: open or compound cranial fractures
depressed greater than the thickness of the cranium, with concern for dural
penetration, significant intracranial hematoma (see above), pneumocephalus
suspicious for presence of dural tear, or contamination. If the fracture
crosses a dural venous sinus, this may represent a complicating consideration
and should be discussed in a multidisciplinary fashion.
· For management of intracranial hypertension in severe TBI, surgical decompression is considered third-line salvage therapy3,9,10.
SIBICC
Algorithm
Education Strategy
TBI patients are cared for by a multi-disciplinary team. To standardize
practice, education will need to be provided to multiple groups, including the trauma/ICU
attendings, APPs, and residents who perform the initial evaluation of and
subsequent management of these patients, the ICU nurses who take care of TBI
patients, the neurosurgery and neurology providers who consult on TBI patients,
and the ED providers who are involved in the initial care of TBI patients. Education
will be provided via didactic sessions, bedside teaching, and the dissemination
of TBI guidelines and posters of the SIBICC intracranial hypertension
management algorithm.
Information Technology Needs
Ordersets for the initial management of severe and moderate TBI as well
as for the management of refractory intracranial hypertension will be developed
for integration into the electronic medical record (EPIC). This will enable providers
to rapidly access the necessary orders for the management of this patient
population. These guidelines link to the following ordersets: ***. Additionally, these
guidelines and algorithms will be uploaded to a readily accessible online
database (CareWeb as well as the UK Trauma Protocol Manual Blogspot, https://uktraumaprotocol.blogspot.com/)
for ease of reference.
References
1. Guidelines for the Management of Severe
TBI, 4th Edition. Brain Trauma Foundation. Accessed August 29, 2025.
https://braintrauma.org/coma/guidelines/severe-tbi
2. ACS Releases Revised Best Practice Guidelines in Management
of Traumatic Brain Injury. ACS. Accessed August 29, 2025.
https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/october-29-2024-issue/acs-releases-revised-best-practice-guidelines-in-management-of-traumatic-brain-injury/
3. Hawryluk GWJ, Aguilera S, Buki A, et al. A management
algorithm for patients with intracranial pressure monitoring: the Seattle
International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive
Care Med. 2019;45(12):1783-1794. doi:10.1007/s00134-019-05805-9
4. Roquilly A, Moyer JD, Huet O, et al. Effect of Continuous
Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes
in Patients With Traumatic Brain Injury: The COBI Randomized Clinical Trial. JAMA.
2021;325(20):2056-2066. doi:10.1001/jama.2021.5561
5. Van Beek JGM, Mushkudiani NA, Steyerberg EW, et al.
Prognostic value of admission laboratory parameters in traumatic brain injury:
results from the IMPACT study. J Neurotrauma. 2007;24(2):315-328.
doi:10.1089/neu.2006.0034
6. Hawryluk GWJ. Editorial. Sodium values and the use of
hyperosmolar therapy following traumatic brain injury. Neurosurg Focus.
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7. Wells DL, Swanson JM, Wood GC, et al. The relationship
between serum sodium and intracranial pressure when using hypertonic saline to
target mild hypernatremia in patients with head trauma. Crit Care.
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Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J
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doi:10.1016/j.annemergmed.2022.01.045
13. Knack SKS, Robinson AE, Beilman GJ, Bhardwaj A, Puskarich MA.
The Association of Lowest Prehospital Blood Pressure with Mortality in Severe
Traumatic Brain Injury from a Nationwide Emergency Medical Services Database. Prehosp
Emerg Care. Published online January 13, 2025:1-10.
doi:10.1080/10903127.2024.2433153
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traumatic brain injury is associated with lower mortality. J Trauma Acute
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doi:10.1007/s12028-015-0222-x
19. Holzmacher JL, Reynolds C, Patel M, et al. Platelet
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antiplatelet therapy. Brain Inj. 2018;32(3):325-330.
doi:10.1080/02699052.2018.1425804
20. Holland C, Hall D, Hall J, Shaffer L, Chambers LW. Platelets
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21. Wolff C, Muakkassa F, Marley R, et al. Routine platelet
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