Key Points

  • Study findings suggest a 30° head elevation reduces ICP and improves CPP post TBI.
     
  • Elevating the head of the bed post TBI is effective at lowering intracranial pressure in children, although the impact on CPP was minimal.
     
  • Although hypothermia has been shown to reduce elevated ICP by some researchers there is no solid evidence to support its effectiveness post ABI. More research needs to be done.
     
  • Systemic hypothermia increases the risk of pneumonia post ABI.
     
  • Tromethamine counteracts the detrimental effects of prolonged hyperventilation for the control of ICP leading to better outcomes post-ABI.
     
  • Hyperoxia may counteract the adverse effects of prolonged hyperventiliation for the control of ICP post-ABI. 
     
  • Hyperventilation below 34 torr PaCO2 may cause an increase in hypoperfused brain tissue.
     
  • CSF drainage has been found to reduce ICP and increase CPP in those who have sustained an ABI.
     
  • In adults standard trauma craniectomy leads to better control of ICP and better clinical outcomes at 6 months when compared with limited craniectomy
     
  • Resection of a larger bone flap during craniectomy may lead to a greater reduction in ICP, better patient outcomes and fewer post-surgical complications
     
  • Although decompressive cranectomy does reduce ICP in children more research needs to be conducted investigating its impat on the long term clinical outcomes.
     
  • Continuous rotational therapy may not worsen intracranial pressure in severe brain injury patients
     
  • Prone position may increase oxygenation and cerebral perfusion pressure in patients with acute respiratory insufficiency.
     
  • Hypertonic saline reduces ICP more effectively than mannitol.
     
  • Hypertonic saline and Ringer’s lactate solution are similar in lowering elevated ICP and result in similar clinical outcomes and survival up to 6 months post-injury.
     
  • In children, use of hypertonic saline in the ICU setting results in a lower frequency of early complications and shorter ICU stays compared with Ringer’s lactate in children.
     
  • Saline results in decreased mortality rates compared to albumin.
     
  • Hypertonic saline may reduce elevated ICP uncontrolled by conventional ICP management measures.
     
  • Hypertonic saline may aid in resuscitation of brain injured patients by increasing cerebral oxygenation.
     
  • Sodium lactate is more effective than mannitol for reducing acute elevations in ICP.
     
  • High dose mannitol results in lower mortality rates and better clinical outcomes compared with conventional mannitol.
     
  • Early out of hospital administration of mannitol does not negatively affect blood pressure.
     
  • Mannitol may only lower ICP when initial ICP values are abnormally elevated.
     
  • Propofol may help to reduce ICP and the need for other ICP and sedative interventions when used in conjunction with morphine.
     
  • Infusions of propofol greater than 4mg/kg per hour should be undertaken with extreme caution.
     
  • Midazolam has no effect on ICP but may result in systemic hypotension.
     
  • Bolus opioid administration results in increased ICP.
     
  • There is conflicting evidence regarding the effects of opioid infusion on ICP.
     
  • Remifentanil results in faster arousal compared to hypnotic based sedation.
     
  • There are conflicting reports regarding the efficacy of pentorbarbital for the control of elevated ICP.
     
  • Thiopental is beter than pentobarbital for controlling unmanageable refractory ICP.
     
  • Pentobarbital is not better than mannitol for the control of elevated ICP.
     
  • Barbiturate therapy plus hypothermia may improve clinical outcomes.
     
  • Patients undergoing barbiturate therapy should have their immunological response and systemic blood pressure monitored.
     
  • Dexanabinol is not effective in controlling ICP or in improving clinical outcomes post-ABI.
     
  • Methylprednisolone increases mortality rates in ABI patients and should not be used.
     
  • Triamcinolone may improve outcomes in patients with a GCS<8 and a focal lesion.
     
  • Dexamethasone does not improve ICP levels and may worsen outcomes in patients with ICP > 20mmHg
     
  • Glucocorticoid administration may increase the risk of developing first late seizures.
     
  • Progesterone decreases 30-day mortality rates.
     
  • Progesterone improves GOS and modified FIM scores at 3 and 6 months post-injury.
     
  • Some bradykinin antagonists prevent acute elevations in ICP but their effects on long-term clinical outcomes are uncertain.
     
  • Dimethyl sulfoxide may cause temporary reductions in ICP elevations post-ABI.
     
  • Sensory stimulation provided by family members improves consciousness for patients with GCS 6-8.
     
  • Sensory stimulation may help to promote emergence from coma or vegetative state post ABI.
     
  • Music therapy might be useful in promoting emergence from coma post ABI.
     
  • Median nerve electrical stimulation does not improve emergence from coma post-ABI.
     
  • Amantadine may improve consciousness and cognitive function in comatose ABI patients.
     
  • Dopamine enhancing drugs may facilitate rate of recovery post traumatic brain injury in children; however, due to the small sample sizes more definitive research is needed.