Question 27

Strategy

Rationale

Endotracheal intubation

Prevention of hypoxaemia by preventing airway obstruction and/or aspiration, facilitates mechanical ventilation

Controlled mechanical ventilation

O₂ saturation >95%

PaCO₂ 32 – 38 mmHg (4.2 –

5.0 kPa)

Avoidance of hypoxaemia, 

Avoidance of hypercarbia which can lead to cerebral vasodilation and increased ICP

Avoidance of hypocarbia with consequent cerebral vasoconstriction and relative ischaemia

Cervical spine immobilisation

Cervical spine injury is commonly associated with traumatic brain injury

Maintain an adequate blood pressure

Systolic BP >110

MAP 80-120 if CPP measured and ICP>20

Hypotension is associated with poorer neurological outcome

Hypovolaemia is common in trauma patients due to associated injuries

Avoid the use of albumin for fluid resuscitation

Albumin is associated with poorer outcomes in patients with TBI

Avoid cerebral venous hypertension

Care with ETT tapes

C-spine collars

Elevate head of bed 30-45^o

Obstructed venous drainage can contribute to intracranial hypertension

Maintain normothermia  Temperature 36-37^o

Elevated temperature increases cerebral metabolic demand

Hypothermia has not yet been shown to be associated with improved outcomes 

Maintain normoglycaemia  BSL 6-10 mMol/L

Hypoglycaemia exacerbates cerebral injury

Avoid hyponatraemia  Na 140-145 mMol/L

Hyponatraemia can contribute to cerebral oedema and raised intracranial pressure

Early       detection               of            surgically correctable secondary lesion

ICP monitoring

Low threshold for repeat CT scan if deterioration in clinical neurological state

Early identification of a surgically correctable lesion

Reaccumulation of extra-axial collection

Hydrocephalus

New intraparenchymal haemorrhage

Surgical intervention may prevent further neurological damage

Monitoring of and treatment for intracranial hypertension

 ICP <20

Strategies to treat intracranial hypertension (in addition to those mentioned above)

Sedation

Neuromuscular paralysis

Induction of mild hyperosmolar state

Detect and treat seizures

Convulsive and non-convulsive epileptic seizures, increase cerebral metabolic demand