Traumatic Brain Injury & ICP Management

Catastrophic Hemorrhage & Cerebral Perfusion
Defense (<C>ABC): Arrest external hemorrhage; establish two 14–16G IVs. Eliminate Hypotension &
Hypoxia Immediately: Target SpO₂ 94–98% (PaO₂ 80–120 mmHg) and age-specific Systolic Blood Pressure: SBP ≥ 100 mmHg (ages 50–69) or SBP ≥ 110 mmHg (ages 15–49 and ≥70 years); MAP ≥ 80 mmHg [1,2]. Start Norepinephrine 0.05–0.3 mcg/kg/min (plus isotonic crystalloid/blood if hypovolemic) if SBP falls below target.

Prevents the two most lethal secondary brain insults: a single episode of SBP < 90 mmHg doubles TBI mortality, and combined hypoxia (SpO₂ < 90%) + hypotension increases mortality nearly three-fold by collapsing Cerebral Perfusion Pressure (CPP = MAP − ICP) [1].

Tier-0 Mechanical Venous Outflow Optimization: Elevate head of bed (HOB) to 30° (or reverse Trendelenburg 15–30° if spinal motion restriction is still active). Position head strictly midline; loosen rigid cervical collar front piece while maintaining manual/sandbag stabilization; ensure endotracheal tube ties do not compress the neck [2].

Maximizes cerebral venous drainage through the valveless internal jugular veins, reducing Intracranial Volume (Vblood) via the Monro-Kellie doctrine without dropping MAP [2].

Neuro-Protective RSI (A/B): Perform RSI for GCS ≤ 8, loss of airway reflexes, or agitation preventing CT. Pre-oxygenate to SpO₂ 100%; keep push-dose Phenylephrine (100 mcg/mL) or Norepinephrine infusion running. Induction: Ketamine 1–1.5 mg/kg IV (or Etomidate 0.3 mg/kg IV) + Fentanyl 1–2 mcg/kg IV (to blunt laryngoscopic sympathetic ICP spike, only if SBP ≥ 120 mmHg) + Rocuronium 1.2 mg/kg IV [2]. Set ventilator to strict normocapnia (PaCO₂ 35–40 mmHg, ETCO₂ 30–35 mmHg) [1,2].

Prevents peri-intubation hypotension (↓ CPP), eliminates reflex sympathetic ICP surges during glottic stimulation, and avoids both hypercapnic cerebral vasodilation (↑ ICP) and hypocapnic cerebral vasoconstriction (ischemia) [1,2].

Hyperosmolar Rescue (If Clinical Herniation /
Anisocoria / Cushing Triad): Administer Hypertonic Saline (HTS) 3% NaCl 250 mL (3–5 mL/kg) IV over 10–15 min (or 23.4% NaCl 30 mL IV over 10 min via CVC/IO) OR Mannitol 20%, 0.5–1.0 g/kg IV over 15 min through a filter (avoid Mannitol if hypotensive) [1,2]. If active herniation persists, apply transient hyperventilation (PaCO₂ 30–34 mmHg) for ≤15–30 min as a bridge to the operating room [1,2].

Creates an intravascular-to-interstitial osmotic pressure gradient across the intact blood-brain barrier (reflection coefficient σ = 1.0 for NaCl, 0.9 for Mannitol), extracting parenchymal free water and improving erythrocyte deformability [1,2].

Tranexamic Acid, Anticoagulant Reversal & Seizure
Control (D/E): Administer TXA 1 g IV over 10 min (then 1 g over 8 hr, or 2 g IV bolus) within 3 hours of injury for mild-to-moderate TBI (GCS 9–12) with CT bleed or moderate-to-severe TBI without bilateral fixed dilated pupils [3]. Administer Levetiracetam 20–40 mg/kg (typically 1,500–2,000 mg) IV for early post-traumatic seizure prophylaxis [1,2]. Check point-of-care glucose, reverse anticoagulants (4F-PCC/Vitamin K/Idarucizumab/Andexanet), obtain emergent Non-Contrast Head CT, and alert Neurosurgery.

Arrests fibrinolytic expansion of intracranial hematomas [3], prevents seizure-induced 300% surges in Cerebral Metabolic Rate of Oxygen (CMRO₂), and enables craniotomy within the golden first hour.