›10-unit pool typically raises fibrinogen 1 g/l
›Recheck level after replacement
ICP management (tiered SIBICC approach)
›Tier 0 (basic care for all severe TBI)
›Head of bed 30 degrees, head midline
›Promotes venous drainage
›Avoid hip flexion > 90 degrees
›Normothermia target 36 to 37 degrees C
›Acetaminophen 650 mg IV or PO every 6 hours PRN
›Cooling blanket for refractory hyperthermia
›Euvolemia maintenance
›Isotonic crystalloid to maintain MAP
›Avoid hypotonic fluids (worsen cerebral edema)
›Seizure prophylaxis 7 days
›Levetiracetam 500 to 1000 mg IV every 12 hours
›Renal dose adjustment required
›Preferred over phenytoin (fewer drug interactions)
›Phenytoin 100 mg IV every 8 hours alternative
›Therapeutic drug monitoring required
›QT monitoring needed
›Tier 1 (ICP 22 to 30 mmHg)
›Increase sedation and analgesia
›Propofol dose increase to RASS -3 to -4
›Fentanyl infusion for pain-mediated ICP spikes
›Osmotherapy
›Mannitol 0.25 to 1.0 g/kg IV bolus
›Serum osmolality limit 320 mOsm/kg
›Avoid if serum osmolality already > 310 mOsm/kg
›Hypertonic saline 3% NaCl 250 mL IV bolus alternative
›Target serum sodium 145 to 155 mmol/l
›Central line preferred for concentrations > 3%
›CSF drainage via EVD if in place
›5 to 10 mL aliquots to reduce ICP
›Monitor for infection with prolonged use
›CPP target 60 to 70 mmHg
›Norepinephrine for MAP augmentation if needed
›Start at 0.05 mcg/kg/min, titrate to CPP target
›Tier 2 (ICP > 30 mmHg refractory to Tier 1)
›Mild hyperventilation
›PaCO2 32 to 35 mmHg as temporary measure
›Not sustained > 24 hours without cerebral perfusion monitoring
›Neuromuscular blockade
›Cisatracurium 0.1 to 0.2 mg/kg/h infusion
›Trial dose 0.1 mg/kg IV first
›EEG monitoring while paralyzed
›Rocuronium alternative for shorter duration trials
›MAP augmentation
›Norepinephrine titrated to CPP 60 to 70 mmHg
›Phenylephrine for tachycardia with CPP deficit
›Tier 3 (refractory elevated ICP > 30 mmHg)
›Barbiturate coma
›Pentobarbital 5 to 10 mg/kg IV load over 30 minutes
›Maintenance 1 to 4 mg/kg/h infusion
›Titrate to burst suppression on EEG
›Hypotension is major adverse effect requiring vasopressors
›Decompressive craniectomy
›Bifrontal or unilateral depending on injury pattern
›Rescue option for refractory ICP
›DECRA and RESCUEicp trial evidence informs decision
›Mild hypothermia 35 to 36 degrees C
›Last resort after failure of other tiers
›Rewarming protocol critical to avoid rebound ICP
›Corticosteroids are contraindicated in severe TBI
›CRASH trial demonstrated increased mortality
›Methylprednisolone 2 g IV bolus increased 2-week mortality
›Relative risk 1.18 (95% CI 1.09 to 1.27)
›Class I recommendation against corticosteroid use
›Routine hypothermia not recommended
›Adverse effects outweigh benefit in most trials
›Infection risk and hemodynamic instability
›Eurotherm3235 trial showed harm
Paroxysmal sympathetic hyperactivity treatment
›PSH recognition and management
›Clinical criteria
›Episodic tachycardia HR > 120 beats/min
›Hypertension SBP > 160 mmHg
›Diaphoresis, hyperthermia, tachypnea, posturing
›Pharmacological management
›Propranolol 20 to 60 mg PO every 6 hours
›Beta-1 and beta-2 blockade reduces sympathetic surge
›Titrate to heart rate reduction
›Bromocriptine 2.5 to 5 mg PO every 8 hours
›Dopaminergic mechanism
›First-line for PSH in many centers
›Clonidine 0.1 mg PO every 8 hours
›Central alpha-2 agonist reduces sympathetic outflow
›Sedation risk monitoring required
›Gabapentin 300 mg PO TID titrated to 1200 to 3600 mg/day
›Reduces paroxysmal episodes
›Renal dose adjustment required
›Opioid PRN for acute severe episodes
›Morphine 2 to 4 mg IV PRN
›Covers sympathetic storms during procedures
›Pharmacologic VTE prophylaxis
›Initiate when safe typically 24 to 72 hours post-injury
›Guided by repeat imaging stability (no hematoma expansion)
›Neurosurgery approval required
›Enoxaparin 40 mg subcutaneous daily
›Renal dose adjustment for CrCl < 30 mL/min
›Anti-Xa monitoring in obesity and renal insufficiency
›Unfractionated heparin 5000 units subcutaneous every 8 hours alternative
›If enoxaparin contraindicated
›More easily reversible with protamine
›Mechanical VTE prophylaxis
›Sequential compression devices from admission
›Applied to all extremities without injury
›Continue until ambulatory or pharmacologic prophylaxis started
›Early enteral nutrition within 24 to 72 hours
›BTF guideline recommendation for mortality reduction
›Caloric target 140% of resting metabolic expenditure in non-paralyzed patients
›Caloric target 100% in paralyzed patients
›Nasogastric tube placement if not intubated with NG
›Post-pyloric tube if gastroparesis
›PEG tube for prolonged requirement
›Glucose monitoring and control
›Target 5.6 to 10 mmol/l
›Hypoglycemia particularly harmful to injured brain
›Insulin infusion protocol for hyperglycemia