Management of severe traumatic brain injury: The need for the knowledgeable nurse

Abstract

In the hours and days following severe head injury, the main goals of treatment are to maintain an adequate cerebral perfusion pressure and to reduce and prevent rises in intracranial pressure. In addition, it is imperative to optimize ventilation and minimize systemic complications. Management strategies aim to achieve a cerebral perfusion pressure of >60mmHg and intracranial pressure <20–25mmHg. There are several interventions that are employed to achieve these goals. Some are used as first line treatments, i.e. 30º head elevation, sedation, drainage of cerebrospinal fluid, and others as second-line interventions, i.e. mannitol, mild hyperventilation and induced hypothermia. Surgical interventions include evacuation of mass lesions and decompressive craniectomy. There is a lack of grade I evidence to support most treatments, but guidelines published by the US Brain Trauma Foundation and the European Brain Injury Consortium provide recommendations for management based on the best evidence available. This article reviews the medical and nursing management of the severely head-injured patient during the acute phase in the intensive care unit. It will begin with the presentation of the pathophysiology of injury.