›Hold if serum osmolality > 320 mOsm/kg or euvolemia not achieved
›Hypertonic saline 3%
›Dose 250 mL IV bolus for acute herniation
›Target serum sodium 145 to 155 mmol/l
›May be preferred over mannitol in hypovolemic patients
›Hypertonic saline 23.4%
›Dose 30 mL IV for refractory herniation
›Central line preferred for administration
›Most rapid onset osmotherapy option
›Anticoagulation reversal
›Warfarin reversal
›4-factor PCC — dose based on INR and body weight
›INR 2 to 4: 25 units/kg IV
›INR 4 to 6: 35 units/kg IV
›INR > 6: 50 units/kg IV
›Adjunct vitamin K 10 mg IV for sustained reversal
›Direct oral anticoagulant reversal
›Idarucizumab 5 g IV for dabigatran — Class I recommendation
›Andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)
›4-factor PCC as alternative if specific reversal unavailable
›Antiplatelet reversal
›Platelet transfusion for surgical intervention with aspirin or P2Y12 use
›Desmopressin 0.3 mcg/kg IV for uremic platelet dysfunction adjunct
›Prophylactic antiepileptic therapy
›Levetiracetam — preferred agent for seizure prophylaxis in TBI
›Dose 500 to 1000 mg IV or PO twice daily
›Duration 7 days for early post-traumatic seizure prevention
›BTF guideline Level IIA recommendation
›Phenytoin — alternative
›Loading dose 20 mg/kg IV at maximum rate 50 mg/min
›Maintenance 5 mg/kg/day IV or PO in divided doses
›Monitor for cardiac arrhythmia and hypotension during IV loading
›Indications for prophylaxis
›GCS < 10
›Cortical contusion on CT
›Depressed skull fracture
›Penetrating head injury
›Early post-traumatic seizure
›Active seizure treatment
›Benzodiazepine first line
›Lorazepam 0.1 mg/kg IV at 2 mg/min
›Midazolam 10 mg IM if no IV access
›Diazepam 5 to 10 mg IV as alternative
›Second-line agents if seizure continues beyond 5 minutes
›Levetiracetam 60 mg/kg IV (max 4500 mg) over 10 minutes
›Fosphenytoin 20 mg PE/kg IV at max 150 mg PE/min
›Valproate 40 mg/kg IV at max 6 mg/kg/min
›Conservative measures — first-line
›Positional measures
›Head of bed elevation to 30 degrees
›Bed rest with activity restriction
›Avoid nose blowing, straining, Valsalva maneuver
›Stool softeners to prevent straining
›Docusate sodium 100 mg PO twice daily
›Polyethylene glycol 17 g PO daily as alternative
›Duration — majority of CSF leaks resolve within 7 days with conservative management
›Escalation for persistent CSF leak
›Lumbar drain
›Consider if CSF leak persists beyond 3 to 5 days of conservative management
›Target drainage 5 to 10 mL/hour
›Monitor for headache, over-drainage, meningitis
›Surgical repair
›IDSA strong recommendation if CSF leak persists beyond 7 days
›Endoscopic endonasal repair preferred when anatomically feasible
›Intrathecal fluorescein assists intraoperative defect identification
›Prophylactic antibiotics — NOT recommended
›Evidence base
›Cochrane review — no demonstrated reduction in meningitis with prophylaxis
›IDSA strong recommendation against prophylactic antibiotics
›AAST consensus against prophylaxis
›2026 nationwide cohort study confirmed no benefit
›Risk of prophylaxis
›Selects for resistant organisms
›No change in meningitis incidence or mortality
›Vaccination
›Pneumococcal vaccination recommended for patients with CSF leak
›IDSA strong recommendation
›PCV15 or PCV20 preferred in adults
›Administer once acute phase resolved if not up to date
›Therapeutic antibiotics — only for confirmed meningitis
›Empiric regimen for post-traumatic bacterial meningitis
›Ceftriaxone 2 g IV every 12 hours
›Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours — covers resistant pneumococcus
›Dexamethasone 0.15 mg/kg IV every 6 hours for 4 days adjunct
Cranial nerve and vascular injury management
›Facial nerve palsy
›Initial management — conservative observation
›Delayed onset palsy has better prognosis than immediate onset
›Eye protection with lubricating drops and tape for incomplete closure
›Ophthalmology consultation if corneal exposure
›Corticosteroids for selected cases
›Consider for severe delayed-onset facial palsy
›Prednisolone 1 mg/kg/day PO for 5 to 7 days
›Surgical decompression in selected cases
›ENT decision based on electromyography results
›High-grade degeneration on nerve conduction studies
›Vascular injury — carotid dissection
›Anticoagulation or antiplatelet therapy
›Decision based on hemorrhagic complication risk
›Aspirin 325 mg PO daily if anticoagulation contraindicated by intracranial hemorrhage
›Heparin infusion if no intracranial hemorrhage and high stroke risk
›Interventional neuroradiology consultation for stenting if refractory