Table 1.
Comparison of BTF Recommendations (3rd Edition) for severe TBI and status of locally available treatment in Tanzania.
| Topic | BTF Recommendation | Data Class* |
Status in Tanzania |
|---|---|---|---|
|
| |||
| Monitoring | |||
|
| |||
| Blood Pressure | • Monitor blood pressure in all patients | II | Available |
|
| |||
| Oxygenation | • Monitor oxygen saturation in all patients | III | Available |
|
| |||
| Intracranial Pressure (ICP) | • Monitor ICP in patients with severe TBI and an abnormal CT scan | II | Unavailable |
| • Monitor ICP in patients with severe TBI and a normal CT scan if ≥ 2 of the following present at admission: age >40y/o, unilateral or bilateral motor posturing, SBP <90mmHg | III | Unavailable | |
|
| |||
| Brain Oxygen | • Monitor jugular venous saturation or brain tissue oxygen for cerebral oxygenation | III | Unavailable |
|
| |||
| Cerebral Perfusion | • Monitor cerebral perfusion parameters including blood flow, oxygenation, and metabolism to facilitate CPP management | III | Unavailable |
|
| |||
| Thresholds | |||
|
| |||
| Blood Pressure | • Treat SBP<90mmHg | II | Attempted |
|
| |||
| Oxygenation | • Treat PaO2 <60 mm Hg or O2 saturation <90% | III | Attempted |
|
| |||
| ICP | • Treat ICP > 20 mm Hg | II | Unable to monitor |
| • Use ICP values, clinical and brain CT findings to determine need for treatment | III | Unable to monitor ICP | |
|
| |||
| Brain Oxygen | • Treat jugular venous saturation <50% or brain tissue oxygenation tension <15 mmHg | III | Unable to monitor |
|
| |||
| Cerebral Perfusion | • Avoid aggressive attempts to maintain cerebral perfusion pressure (CPP) above 70 mm Hg with fluids and vasopressors because of the risk of adult respiratory distress syndrome (ARDS) | II | Unable to monitor |
| • Target CPP 50–70 mm Hg. Patients with intact pressure autoregulation tolerate higher CPP | III | Unable to monitor | |
| • Avoid CPP of < 50 mm Hg. | III | Unable to monitor | |
|
| |||
| Treatments | |||
|
| |||
| Hyperosmolar Therapy for elevated ICP | • Mannitol (0.25 gm/kg to 1 gm/kg) is effective | II | Available and used |
| • Before ICP monitoring, use only for signs of transtentorial herniation or progressive neurological deterioration | III | Available and used | |
| • No current recommendation for use of hypertonic saline | -- | ||
|
| |||
| Prophylactic Hypothermia | • Does NOT decrease mortality | III | Unavailable |
| • Increases GOS scores | |||
|
| |||
| Infection Prophylaxis | • Antibiotics before intubation reduce pneumonia incidence (but NOT LOS or mortality) | II | Available and used |
| • Early tracheostomy reduces ventilator days (but does NOT reduce mortality or pneumonia) | II | Available and used | |
| • Do NOT routinely change ventricular catheters | III | Catheters unavailable | |
| • Do NOT use prophylactic antibiotics for duration of ventricular catheter placement | |||
| • Early extubation does not increase pneumonia | III | Available, not used | |
|
| |||
| Deep Vein Thrombosis Prophylaxis | • Use graduated compression stockings or intermittent pneumatic compression stockings | III | Unavailable |
| • Use low molecular weight heparin or low dose unfractionated heparin in combination with mechanical prophylaxis | III | Available, not used | |
| • There is an increased risk of expansion of intracranial hemorrhage | |||
| • Insufficient evidence for preferred agent, dose, or timing of pharmacologic DVT prophylaxis | |||
|
| |||
| Anesthetics, analgesics, and sedatives | • Do NOT use prophylactic high dose barbiturate coma | II | Available, not used for coma |
| • Barbiturate coma may be used to control elevated ICP refractory to maximum medical and surgical treatment | II | Available, not used for coma | |
| • Propofol can improve ICP but NOT mortality or 6 month outcomes. High dose propofol can produce significant morbidity | II | Unavailable | |
|
| |||
| Nutrition | • Feed to full caloric needs by day 7 post-injury | II | NG feeds used, but caloric content unmeasured |
|
| |||
| Anti-seizure Prophylaxis | • Do NOT use prophylactic phenytoin or valproate for late posttraumatic seizures (PTS) prevention | II | Available and used |
| • Use Anticonvulsants to decrease incidence of early PTS within 7 days of injury. However, early PTS is NOT associated with worse outcomes | II | ||
|
| |||
| Hyperventilation | • Do NOT use prophylactic hyperventilation | II | Available, not used. |
| • Use hyperventilation only as a temporary measure to reduce ICP | III | ||
| • Avoid hyperventilation in initial 24 hours after injury | III | ||
|
| |||
| Steroids | • Do NOT use steroids to improve outcomes or reduce intracranial pressure. High dose methylprednisolone increases mortality. | I | Available, not used |
*
Data Class according to BTF guidelines, see Table 1 of the BTF guidelines for details16