Acute severe head injury: multimodal monitoring

^[2]

A 24-year-old man with severe diffuse TBI has an ICP in the mid-teens and CPP in the seventies — both inside target — but a PbtO2 below 15 mmHg. Brain hypoxia below 15 mmHg carries its own prognostic weight after adjustment for ICP and CPP, so the normal pressure does not close the question.^[9]

ICP — treat above 22, and know what the tiers are

The BTF fourth edition recommends treatment of ICP sustained above 22 mmHg, a recommendation derived mainly from a single retrospective analysis of 459 TBI patients that aimed to identify management thresholds for ICP, CPP and PRx.^[21] An external ventricular drain both measures and drains; the silver-impregnated catheter did not significantly reduce catheter-related CSF infection (pooled OR 0.71, 95% CI 0.46-1.08), though Gram-positive infections were fewer.^[13]

The 2017 medical review summarises the rest of the BTF landscape: decompressive craniectomy is not recommended to improve 6-month outcomes in patients without a mass lesion and refractory ICP (DECRA, 155 patients); RESCUEicp randomised patients with ICP sustained above 25 mmHg for 1-12 hours after aggressive medical management; prophylactic hyperventilation and corticosteroids are addressed by dedicated recommendations; phenytoin carries a Level II A recommendation for 7 days post injury for early post-traumatic seizure prevention.^[21]

The counterpoint is BEST:TRIP — 324 severe TBI patients in Bolivia and Ecuador randomised to ICP-monitoring-based care (treat at 20 mmHg or less) or imaging-and-examination-based care, with no shown superiority for monitoring.^[7]

^[13]

References21ShowHide

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