A summary of the Brain Trauma Foundation guidelines

With the recent publication of the new BTF guidelines (at bloody last) the topic of severe brain injury becomes more likely to appear in the fellowship exam. The aim of this page is to have a list of the BTF directives collected in one spot to allow rapid revision. Wherever possible, the normal urge to explore to the nth degree of fine detail has been suppressed in favour of brevity.

The links to the specific guideline statement are available below (the bold headings). If one wishes to examine the evidence in greater detail, one is invited to explore the original  244 page document.  

Decompressive craniectomy:

• Recommended to improve mortality and other favourable outcomes in early and late refractory ICP elevation 
• Shorter ICU stay, lower ICP and less ICP-targeting interventions are the expected benefit (Hawryluk et al, 2020)

"Prophylactic" hypothermia (early, to prevent secondary brain injury)

• Does not improve outcome.

Osmotherapy

• Mannitol (restrict its use to herniating patients)
• Still not enough evidence for hypertonic saline to make a firm recommendation

Draining the CSF

• Continuous drainage is better than intermittent
• Drain CSF for the first 12 hours from patients with a GCS of less than 6

Ventilation

• Avoid hyperventilation, especially in the first 12 hours
• If you are going to hyperventilate the patient, use jugular venous saturation monitoring to ensure the brain is getting enough oxygen

Sedation

• Propofol is recommended for routine ICP control
• Barbiturate coma is reserved for super-refractory ICP

Steroids

• The only Level I recommendation in the whole package is "steroids are bad".

Nutrition

• Aim to achieve goal nutrition by the 5th-7th day

Prophylactic antibiotics

• Use routine protocol to prevent VAP; no need for prophylactic antibiotics

DVT prophylaxis

• "Stable" TBI should have TED stockings and heparin or clexane

Seizure prophylaxis

• Seven days of phenytoin

ICP monitoring

• Indicated if GCS is 3-8 and an abnormal CT
• Indicated if GCS is 3-8, there is a normal CT, and any two of the following
  • Age over 40
  • Motor posturing
  • Hypotension (SBP under 90 mmHg)
• An ICP of 22mmHg is the threshold for treatment

CPP monitoring

• Use CPP-guided management; aim for a CPP of 60-70

Advanced cerebral monitoring

• No support for this practice (no mortality benefit)
• Jugular bulb monitoring should be used to guide decisions

Systolic blood pressure target:

• 110 mmHg  for the young (18-49)
• 110 mmHg and elderly (over 70),
• 100 mmHg for the 50-69 age group