Management of severe traumatic brain injury (first 24 hours)

Overview

These guidelines were published in 2018 in Anaesthesia Critical Care & Pain Medicine by the French Society of Anaesthesia and Intensive Care Medicine (SFAR), together with Anarlf, SFMU, SFN, GFRUP and Adarpef. They update the French recommendations of 1998 for the first 24 hours after severe traumatic brain injury (TBI), taking account of advances in intracerebral monitoring, cerebral perfusion pressure management and treatment of raised intracranial pressure. Mild and moderate injuries and later management are not covered.

Methods

Experts used the GRADE method and two Delphi rounds to produce 32 recommendations on 11 topics: 10 strong, 18 weak and 4 expert opinions. All reached strong agreement.

Key recommendations

Severity is assessed with the Glasgow coma scale, especially the motor response, and pupil size and reactivity. Secondary insults, particularly hypotension and hypoxaemia, must be sought and corrected. Patients should be managed by a medicalised prehospital team and taken to a centre with neurosurgery. Ventilation is controlled with end-tidal CO2 monitoring, and a brain and cervical CT scan is performed without delay. Intracranial pressure monitoring is suggested in defined situations, such as CT signs of raised pressure. Cerebral perfusion pressure is individualised, or kept between 60 and 70 mmHg without multimodal monitoring. Mannitol or hypertonic saline treats threatened intracranial hypertension, whereas prolonged hypocapnia, 4% albumin, high-dose corticosteroids and routine antiepileptic prophylaxis are not advised. Blood glucose is kept between about 8 and 10 mmol/L.

Multiple trauma and children

In multiple trauma a whole-body CT is considered once haemodynamics are stable, and non-life-saving haemorrhagic surgery is avoided during intracranial hypertension. In children, ICP monitoring is suggested, minimum perfusion pressure targets depend on age, and care should be in a paediatric trauma centre or an adult centre with paediatric expertise.