Table 1.
Basic Care Protocol for sTBI Patients
| 1. Patient monitoring measures: We strongly suggest using these interventions whenever available and/or possible. |
| a. Place continuous SaO2 and EtCO2 monitors |
| b. Insert indwelling urinary catheter to monitor urine output |
| c. Insert arterial catheter for arterial pressure monitoring |
| d. Insert central venous catheter for infusion of solution and central venous pressure monitoring |
| e. Monitor clinical neurological status each hour |
| i. Pupil size and reactivity |
| ii. GCS |
| f. Obtain brain CT |
| i. To evaluate evolution 48 h after the admission CT |
| ii. To evaluate evolution 5–7 days after the admission CT |
| iii. As needed based on patient clinical condition |
| 2. General management measures |
| a. Place patient on mechanical ventilation, goal SaO2 > 90% and PaO2 > 60 mm Hg |
| b. Use adequate sedation and analgesia |
| i. Acceptable medications include benzodiazepines, opioids, propofol, and low-dose barbiturates |
| 1. Low-dose barbiturate dosing: |
| a. Thiopental 1-2 mg/kg/h IV continuous infusion (∼1.5-3 g/day) |
| c. Maintain head of bed at 30° |
| d. Maintain head and neck aligned and in neutral position |
| e. Actively monitor body temperature and treat hyperthermia |
| f. Hyperthermia defined as central temperature ≥38°C |
| i. Non-pharmaceutical cooling measures |
| 1. Cooling blanket, ice packs |
| ii. Pharmaceutical cooling measures |
| 1. Metamizole sodium |
| g. Early enteral nutritional support |
| i. Initiate within 48 h of injury |
| ii. Give 25 kcal/kg patient weight per day |
| h. Pharmacologic prophylaxis for early post traumatic seizures |
| i. Phenytoin (IV or PO) |
| 1. Loading and maintenance doses as per individual hospital guidelines |
| 2. Continue for 7–28 days |
| i. Gastric bleeding prophylaxis |
| i. Ranitidine or Omeprazole (IV or PO) |
| 1. Administer as per individual hospital guidelines |
| j. Prevent decubitus lesions and treat as indicated |
| k. Deep venous thrombosis prophylaxis |
| l. Frequent tracheal suctioning with sterile technique to prevent pulmonary infections |
| m. Maintain Hb ≥7 mg/dL, use blood transfusions as needed |
| 3. Treatment goals for adequate cerebral perfusion and oxygenation |
| a. Avoid hypotension—SBP >90 mm Hg, MAP >70 mm Hg |
| b. Arterial blood oxygen saturation (SaO2) > 90% or PaO2 > 60 mm Hg |
| 4. CT scans |
| a. First CT: upon hospital admission |
| b. Second CT: 48 h after the first CT |
| c. Third CT: 5–7 days after the first CT |
| d. Additional CT scans as needed based on patient clinical condition |
| 5. Initial therapeutic interventions |
| a. Normal saline solution (0.9% NaCl) to obtain a CVP of 10-12 cm H2O |
| b. Vasopressors when necessary to obtain a SBP >90 mm Hg or MAP >70 mm Hg |
| c. Maintain PaCO2 35-40 mm Hg if CT is normal (correcting for altitude) |
| d. If a space-occupying lesion exists, surgical evacuation is indicated if possible |
sTBI, severe traumatic brain injury; SaO2, oxygen saturation; EtCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; CT, computed tomography; IV, intravenous; PO, orally; Hb, hemoglobin; CVP, central venous pressure; MAP, mean arterial pressure.