Analgesia, nausea control, and supportive care
› Symptom control
› Acetaminophen 15 mg/kg PO or IV
› Maximum 1000 mg per dose
› Maximum 4000 mg per day
› Opioid analgesia if severe pain
› Fentanyl 0.5 to 1 mcg/kg IV
› Repeat dosing as needed with monitoring
› Antiemetic therapy for vomiting
› Ondansetron 4 mg IV
› Repeat 4 mg IV if needed
› CSF leak precautions
› If suspected CSF rhinorrhea or otorrhea, avoid nasogastric tube
› Intracranial placement risk in basilar fracture
› If suspected CSF leak, avoid nasal positive pressure when possible
› Reduced pneumocephalus risk
Open and depressed fracture infection prevention
› Antibiotic strategy
› Open skull fracture prophylaxis recommended in trauma practice guidelines
› EAST open fractures guidance supports prophylactic antibiotics for open skull fractures
› If open skull fracture without gross contamination, cefazolin 2 g IV every 8 hours
› Duration 72 hours in some institutional protocols
› SurgicalCriticalCare craniofacial guidance includes cefazolin 2 g IV every 8 hours for 3 days
› If open skull fracture with gross contamination, broader coverage per local protocol
› Ampicillin-sulbactam 3 g IV every 6 hours as an option
› Institutional trauma protocols include this approach for open skull fractures
› Tetanus prophylaxis per immunization status
› Tdap booster if indicated
› Tetanus immune globulin if high-risk and not immunized
› Basilar skull fracture antibiotics
› Prophylactic antibiotics not recommended for closed basilar skull fracture with or without CSF leak
› Cochrane systematic review evidence does not support prophylactic antibiotics
› AAST clinical consensus guidance does not recommend prophylactic antibiotics for post-traumatic CSF leaks
Seizure prevention and management
› Anticonvulsant considerations
› If depressed skull fracture with cortical injury, early seizure risk
› Levetiracetam 1000 mg IV load
› Maintenance 500 to 1000 mg PO or IV every 12 hours
› Typical duration 7 days in early post-traumatic seizure prophylaxis practice
› If active seizure, benzodiazepine first-line
› Lorazepam 0.1 mg/kg IV
› Maximum 4 mg per dose
› If persistent, levetiracetam 60 mg/kg IV load
› Maximum 4500 mg
Elevated intracranial pressure and herniation syndromes
› ICP management bundle
› Head of bed elevation 30 degrees
› Neutral neck position
› Hyperosmolar therapy for clinical herniation or progressive deterioration not otherwise explained
› Mannitol 0.25 to 1 g/kg IV
› Brain Trauma Foundation severe TBI guidance supports mannitol for raised ICP (Level II)
› Avoid hypotension SBP under 90 mmHg during therapy
› Hypertonic saline option
› 3% saline 2 mL/kg IV bolus
› Maximum bolus volume per local protocol
› Ventilation strategy
› If impending herniation, brief hyperventilation to PaCO2 30 to 35 mmHg
› Bridge to definitive therapy and neurosurgical intervention
› Sedation for ventilated patients
› Propofol infusion 5 to 50 mcg/kg/min
› Titrate to sedation goal while maintaining blood pressure
› Hypotension avoidance priority in brain injury
Show 32 more ▾