30 degrees or reverse Trendelenburg will lower ICP
Keep head and neck in neutral position, improving cerebral venous drainage
Avoid compressing IVJ or EVJ with tight C-collars or fixation of ETT
CPP = MAP-ICP
If MAP <80, then CPP<60
Ultimately no Class 1 evidence for optimal CPP
Transfuse PRBCs with goal Hb > 10 mg/dL in severe TBI
Provide fluids and vasopressors if needed for goal cerebral perfusion<unk>  (CPP) of 70-80 mmHg
Mortality increases 20% for each 10 mmHg loss of CPP
Avoid dips in CPP < 70 mmHg, which is associated with cerebral ischemia and glutamate increase
Vasopressors
Phenylephrine increases CPP without increasing ICP in animal models
May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)
Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI
IV fluids
Maintain euvolemia, initially resuscitate with Normal Saline
Then consider hypertonic saline and/or mannitol
Do not use free water, low osmolal, dextrose-alone solutions, and colloids
Do not use Ringer's lactate as it is slightly hypotonic
Prefer NS over D5-NS if possible, but D5-NS may be necessary to avoid hypoglycemia, especially in younger pediatric patients
Correction of severe hypernatremia > 160 mmol/L (hypothalamic-pituitary injury, diabetes insipidus) should be gradual to not worsen cerebral edema
If MAP <80, then CPP<60
Ultimately no Class 1 evidence for optimal CPP
Mortality increases 20% for each 10 mmHg loss of CPP
Avoid dips in CPP < 70 mmHg, which is associated with cerebral ischemia and glutamate increase
Phenylephrine increases CPP without increasing ICP in animal models
May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)
Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI
Maintain euvolemia, initially resuscitate with Normal Saline
Then consider hypertonic saline and/or mannitol
Do not use free water, low osmolal, dextrose-alone solutions, and colloids
Do not use Ringer's lactate as it is slightly hypotonic
Prefer NS over D5-NS if possible, but D5-NS may be necessary to avoid hypoglycemia, especially in younger pediatric patients
Correction of severe hypernatremia > 160 mmol/L (hypothalamic-pituitary injury, diabetes insipidus) should be gradual to not worsen cerebral edema
Therapies include either mannitol or hypertonic saline. In choosing the appropriate agent, coordinate with neurosurgery and take into account the patient's blood<unk> . Mannitol may cause hypotension due to the osmotic diuresis.
If SBP > 90 mmHg
Bolus 20% at 0.25-1 gm/kg as rapid infusion over 15-20 min
Target Osm 300-320 mOsm/kg
Reduces ICP within 30min, duration of action of 6-8hr
Monitor I/O to maintain euvolemia during expected diuresis and use normal saline to volume replace
Do not use continuous infusions, as mannitol crosses the BBB after prolonged administration and contributes to cerebral edema
Consider hypertonic saline for further boluses
Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol
Consider hypertonic saline for further boluses
Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol
Obtain baseline serum osmolarity and sodium
Most studies used 250 mL bolus of 7.5% saline with dextran
Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
Target sodium 145-155 mmol/dL
Hyperventilation does not improve mortality, used only as temporizing measure
Should only be used if reduction in ICP necessary without any other means or ICP elevation refractory to all other treatments:
Sedation
Paralytics
CSF drainage
Hypertonic saline, osmotic diuretics
Maintain PaCO2 35-40 mmHg for only up to 30 minutes, no longer if it can be avoided
Hyperventilation to PaCO2 < 30 mmHg not indicated, and decreases cerebral blood flow to ischemic levels
Sedation
Paralytics
CSF drainage
Hypertonic saline, osmotic diuretics
Treat immediately with benzodiazepines and antiepileptic drugs (AEDs)
Consider propofol for post-intubation sedation
Seizure prophylaxis reduces seizures but does not improve long-term outcomes
AEDs prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review
Risk factors for post-traumatic seizures:
GCS < 10 initially
Cortical contusion
Depressed skull fracture
Subdural hematoma, epidural hematoma
Subarachnoid hemorrhage or ICH
Penetrating head injury
Seizure within 24 hours of injury (immediate seizure)
Treat any clinically apparent and EEG confirmed seizures
Consider prophylaxis in patients with any risk factors as above
Phenytoin or fosphenytoin first line agent by BTF guidelines
Load 20 PE/kg IV, then 100 PE IV q8hrs for 7 days
Measure serum levels to titrate to therapeutic levels
Levetiracetam may be used as alternative
20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days
Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
AEDs prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review
Risk factors for post-traumatic seizures:
GCS < 10 initially
Cortical contusion
Depressed skull fracture
Subdural hematoma, epidural hematoma
Subarachnoid hemorrhage or ICH
Penetrating head injury
Seizure within 24 hours of injury (immediate seizure)
GCS < 10 initially
Cortical contusion
Depressed skull fracture
Subdural hematoma, epidural hematoma
Subarachnoid hemorrhage or ICH
Penetrating head injury
Seizure within 24 hours of injury (immediate seizure)
Consider prophylaxis in patients with any risk factors as above
Phenytoin or fosphenytoin first line agent by BTF guidelines
Load 20 PE/kg IV, then 100 PE IV q8hrs for 7 days
Measure serum levels to titrate to therapeutic levels
Levetiracetam may be used as alternative
20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days
Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
Load 20 PE/kg IV, then 100 PE IV q8hrs for 7 days
Measure serum levels to titrate to therapeutic levels
20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days
Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
Goal cerebral perfusion<unk>  (CPP) ~70mmHg
If need for RSI, consider pretreatment with lidocaine and/or fentanyl
May contribute to peri-intubation hypotension
Also ensure adequate sedation (prevent gag reflex)
Etomidate may cause adrenal insufficiency especially in head injured patients, so consider hydrocortisone if refractory hypotension post-intubation
May contribute to peri-intubation hypotension
Provide adequate sedation and analgesia
Avoid HYPERthermia and treat fever aggressively
However, hypothermia is not a necessary goal
Moderate hypothermia 32°C to 34°C controversial, large RCT showed no effect
However, hypothermia is not a necessary goal
Moderate hypothermia 32°C to 34°C controversial, large RCT showed no effect
DVT prophylaxis with SCDs, no anticoagulation
Stress ulcer prophylaxis with H2 blocker/PPI and sucralfate to avoid Cushing's ulcers
Good glycemic control, but tight maintenance not supported
Steroids, methylprednisolone contraindicated in severe TBI (risk of death increased in CRASH 2004 trial)
Routine paralysis not indicated
Increased risk of pneumonia and ICU length of stay
However, may be used for refractory ICP elevation
Increased risk of pneumonia and ICU length of stay
However, may be used for refractory ICP elevation
For ICP refractory to maximal medical and surgical therapy
Only for hemodynamically stable patients
Induce with the following:
Pentobarbital 10 mg/kg over 30 min
Then 5 mg/kg/hr for 3 hrs
Followed by 1 mg/kg/hr
Pentobarbital 10 mg/kg over 30 min
Then 5 mg/kg/hr for 3 hrs
Followed by 1 mg/kg/hr
Elevated intracranial pressure
Intracranial hemorrhage
Ventriculoperitoneal shunt obstruction
Intra-axial
Post-lumbar puncture headache
Hemorrhagic stroke 
Ventriculoperitoneal shunt overdrainage
Traumatic intracerebral hemorrhage