TBI Checklist

TBI CHECKLIST

  1. ED
    1. hypotension, hypoxia, fluid resuscitation, intubation, assess for spinal fracture and other systemic trauma, GCS
    2. Request for CBC BMP glucose, coags, ETOH, urine tox, CPK
    3. CT ASAP if GCS <14, then routine follow-up CT (parenchymal contrast extravasation – higher risk for progression of hemorrhage)
  2. Neurosurgery referral?
    1. *There was no distortion, dislocation, obliteration of IV, compression of basal cisterns, obstructive HCP.
    2. *Skull fracture not depressed greater than thickness of cranium. There was no dural penetration, hematoma, frontal sinus involvement, cosmetic deformity, wound infection / contamination or pneumocephalus that warranted neurosurgery.
    3. *Indications for surgery: EDH >30ml; SDH >1 cm or MLS >0.5cm; ICH in post fossa with mass effect; ICH in cerebral hemispheres >50 cm3;
  3. Reverse INR
  4. Evaluate for ICP (pupils, posturing, BP, HR, RR)
    1. ICP: elevated HOB, mannitol 1G/Kg IV
  5. Evaluate need for routine prophylactic BSA with cephalosporins

ICU management:

  1. Neurologic:
    1. ICP elevated:
      1. elevate HOB to 30, neck in neutral postion, loosen neck braces; monitor CVP and avoid hypervolemia; ICP goal <20mm Hg; if >20, ventricular drainage – remove CSF 1-2ml/min x 3 mins every 3 mins until ICP <20mm Hg or CSF no longer easily obtained OR by passive gravitational drainage, initiate osmotic therapy with mannitol bolus 0.25-1G/Kg q4-6 PRN, measure POsm, crea, electrolytes, monitor fluid balance (POsm goal <320 mMol/L), hypertonic saline
      2. Barbiturate coma – does not improve 30d mortality, high doses cause hypotension, use only if refractory; load 5-20mg/Kg bolus then 1-4 mg/Kg/hr; continuous EEG, titrate to burst-suppression pattern; may use other benzos or opiates
  • Consider induced hypothermia, decompressive craniectomy
  1. 7-day course of prophylactic phenytoin or valproic acid to reduce risk of early seizures
  2. Keep normothermia with antipyretics, surface cooling devices, endovascular temp management catheters
  3. Keep plt >75K, INR <1.4
  4. CPP goal 60mm Hg (or 50-70)
  5. Keep SjVO2 >60%, keep PbtO2 >25mmHg; keep lactate:pyruvate ratio <40
  6. No steroids
  1. Cardiovascular: maintain SBP >90mm Hg with normal saline, avoid albumin, maintain euvolemia
  2. Fluids and Electrolytes: monitor and correct electrolytes
  3. Pulmonary: maintain PaO2 >60mm Hg, intubate PRN to avoid increase in intrathoracic pressure, avoid hyperventilation first 24-48h following TBI; may consider later but avoid PaCO2 <30mm Hg; sedation with propofol (WOF Propofol Infusion Syndrome)
  4. Endocrine: Target 140-180mg/dL
  5. Hematologic: monitor for TBI-associated coagulopathy, treat Coumadin coagulopathy; maintain platelet >75K à platelet transfusion; keep INR <1.4 à FFP, PCC, Vit K
  6. GI: feed to full caloric replacement by day 7 post injury or earlier
  7. DVT prophylaxis: IPC stockings; hemorrhage expansion greatest in first 24-48h, individualize
  8. Prognosticate:
    1. GCS at presentation, esp motor score; CT abnormalities (SAH, cisternal effacement, MLS), papillary function, age, associated injuries and complications, hypotension, hypoxemia, pyrexia, elevated ICP, reduced CPP, bleeding diathesis (low plt, coagulopathY)
    2. Check other potential biomarkers: s-100B protein, neuron-specific enolase, a-synuclein in blood or CSF
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