Abstract
Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.
Highlights
Severe traumatic brain injury (TBI), defined as head trauma associated with a Glasgow Coma Scale (GCS) score of 3 to 8 [1], is a major and challenging problem in critical care medicine
These results suggested that combined intracranial pressure (ICP)/cerebral perfusion pressure (CPP)- and PbtO2based therapy is associated with better outcome after severe TBI than ICP/CPP-based therapy alone [43]
We reported that the utilization of a clinical practice guidelines-based protocol for severe TBI was associated with a significant reduction in both Intensive Care Unit (ICU) and hospital mortalities [8]
Summary
Severe traumatic brain injury (TBI), defined as head trauma associated with a Glasgow Coma Scale (GCS) score of 3 to 8 [1], is a major and challenging problem in critical care medicine. Coles et al reported that, in patients with TBI, hyperventilation increases the volume of severely hypoperfused tissue within the injured brain, despite improvements in CPP and ICP These reductions in regional cerebral perfusion may represent regions of potentially ischemic brain tissue [59]. High-dose barbiturate may be considered in hemodynamically stable, severe TBI patients with refractory to maximal medical and surgical ICP lowering therapy Their main side effects are: hypotension, especially in volume depleted patients; and immunosuppression with an increased infection rate [116]. In a prospective, randomized controlled trial in 155 adults with severe diffuse TBI and intracranial hypertension that was refractory to first-tier therapies, bifrontotemporoparietal decompressive craniectomy, as compared with standard care, was associated with decreased intracranial pressure (P < 0.001) and length of stay in the ICU (P < 0.001), with more unfavorable outcomes (odds ratio = 2.21; 95% CI = 1.14 - 4.26; P = 0.02). A predictive model based on age, absence of light reflex, presence of extensive subarachnoid hemorrhage, ICP, and midline shift was shown to have high predictive value and to be useful for decision making, review of treatment, and family counseling in case of TBI [132]
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