Guideline for Management of Severe Head Injury

Severe Head Injury

  • Diffuse TBI: GCS < 9 and scan swelling

  • OR GCS > 9 pre intubation + severe CT swelling (Grade DIII or IV)

  • <72 hrs since accident

 

Intensive Care Management

 

VentilationSaO2  > 95% PaO2>90 mHg; PaO2 36-40 mmHg​
Haemodynamic

Arterial line and CVP

IV Fluid to CVP 8-12

Noradrenaline infusion to MAP > 90 mmHg until ICP inserted​

Metabolic

​Serum Na 140 - 155 mmol/L

Maintain BSL to CVP mmol/L and Hb close to 10

Cool to 37°C

SedationMorphine and midazolam​
NursingNurse 20-30 degrees head up, avoid venous obstruction of neck​
ICP & CPP

Only after discussion with the Duty Intensive Care specialist

CPP = MAP – ICP

ICP monitoring:  EVD or parenchymal catheter acceptable

EVD at 20cm – intermittent drainage prn (monitor for 10', drain for 5')

Noradrenaline and/or adrenaline infusion to maintain CPP > 60 mmHg for 1st

48 hrICP elevated:​HTS & Mannitol treatment​

If serum osmo < 315mosm/L & CVP < 12

  •  →  3% HTS bolus 1-200 ml​

If serum osmo < 315 & CVP > 12

  • → mannitol 20% 100 ml iv​

Muscle relaxant

  • Pancuronium 4-8 mg IV

  • If ICP then controlled, increase sedation​

 
  

If ICP > 20mmHg for 4 hours or > 30 mmHg for 1 hour consider:  only after discussion with the duty Intensive Care Specialist:

 

  • Thiopentone 4 mg/Kg bolus

  • If repeated boluses fail to control ICP, then use Thiopentone infusion at 100 mg/hour.

  • If ICP still uncontrolled, consider á Thiopentone to burst suppression using EEG.

  • Cease Thiopentone when ICP controlled <20mmHg for 24 hour.

Page last reviewed: 13 May 2014
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