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.


  • 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


  • 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


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


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


  • 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

CPP monitoring

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


Our beloved Oh's Intensive Care manual has two excellent chapters to dedicate to this topic:

Chapter 43 (pp. 563) Cerebral protection by Victoria Heaviside and Michelle Hayes, and

Chapter 67 (pp. 765) Severe head injury by John A Myburgh.

The only reference really needed for this are the excellent Brain Trauma Foundation Guidelines.

Sydenham, Emma, Ian Roberts, and Phil Alderson. "Hypothermia for traumatic head injury." Cochrane Database Syst Rev 2 (2009).

Herregods, L., et al. "Effect of propofol on elevated intracranial pressure. Preliminary results." Anaesthesia 43.s1 (1988): 107-109.

Trochut, E., et al. "Cerebral hemodynamic and metabolic effects of propofol or thiopental in the treatment of refractory intracranial hypertension in patients with severe traumatic brain injury: A preliminary study: 7AP2‐10." European Journal of Anaesthesiology (EJA) 28 (2011): 101.

D'Hollander, S., et al. "Retrospective analysis of the hemodynamic effects of induction of barbiturate coma in patients with refractory elevated intracranial pressure." Critical Care 17.Suppl 2 (2013): P330.

Roberts, I., and E. Sydenham. "Barbiturate drugs for people with traumatic brain injury." Health (2012).

Selman, Warren R., et al. "Barbiturate-induced coma therapy for focal cerebral ischemia: Effect after temporary and permanent MCA occlusion." Journal of neurosurgery 55.2 (1981): 220-226.

Eisenberg, Howard M., et al. "High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury." Journal of neurosurgery 69.1 (1988): 15-23.

de Nadal, Miriam, et al. "Cerebral hemodynamic effects of morphine and fentanyl in patients with severe head injury: absence of correlation to cerebral autoregulation." Anesthesiology 92.1 (2000): 11.

Roberts, Derek J., et al. "Sedation for critically ill adults with severe traumatic brain injury: A systematic review of randomized controlled trials*." Critical care medicine 39.12 (2011): 2743-2751.

Cooper, D. James, et al. "Decompressive craniectomy in diffuse traumatic brain injury." New England Journal of Medicine 364.16 (2011): 1493-1502.

Edwards, P., et al. "Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months." Lancet 365.9475 (2004): 1957-1959.

Himwich, Williamina A., et al. "Brain metabolism in man: unanesthetized and in pentothal narcosis." American Journal of Psychiatry 103.5 (1947): 689-696.

Backhaus, Samantha. "Secondary Brain Injury." Encyclopedia of Clinical Neuropsychology. Springer New York, 2011. 2220-2221.

Siesjö, B. K., and P. Siesjö. "Mechanisms of secondary brain injury." European journal of anaesthesiology 13.3 (1996): 247-268.

Doberstein, Curtis E., David A. Hovda, and Donald P. Becker. "Clinical considerations in the reduction of secondary brain injury." Annals of emergency medicine 22.6 (1993): 993-997.

Ghajar, Jamshid. "Traumatic brain injury." The Lancet 356.9233 (2000): 923-929.

Hawryluk, Gregory WJ, et al. "Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations." Neurosurgery 87.3 (2020): 427-434.