Closed Head Injury Guidelines

Updated: May 04, 2022
  • Author: Leonardo Rangel-Castilla, MD; Chief Editor: Brian H Kopell, MD  more...
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Guidelines Summary

Brain Trauma Foundation

Brain Trauma Foundation (BTF) Guidelines for Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care. Over their 25-year history, these traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research, as well as novel diagnostics and treatments with which to generate substantially new recommendations. [94]

Brain Trauma Foundation guidelines have been provided for treatment of severe TBI in infants, children, and adolescents. [95]  

Monitoring guidelines include the following:

  • Intracranial pressure (ICP) monitoring is recommended.
  • Advanced neuromonitoring (brain oxygenation) should be reserved for patients with no contraindications to invasive neuromonitoring and for patients who are not brain dead.

Threshold guidelines include the following:

  • Targeting a threshold of under 20 mm Hg in ICP treatment is recommended.
  • Maintaining a minimum cerebral perfusion pressure (CPP) of 40 mm Hg is recommended.

Treatment guidelines include the following:

  • Bolus hyperosmolar therapy (HTS) of 3% saline is recommended for patients with ICP; recommended effective doses range from 2 to 5 mL/kg over 10-20 minutes.
  • For refractory ICP, a bolus of 23.4% HTS is recommended.
  • Avoiding bolus administration of midazolam and/or fentanyl during ICP crises is recommended due to risks of cerebral hypoperfusion.
  • Draining cerebrospinal fluid (CSF) through an external ventricular drain (EVD) is recommended for managing increased ICP.
  • Prophylactic treatment is recommended for reducing the occurrence of early (within 7 days) posttraumatic seizures (PTSs).
  • Moderate (32-33°C) hypothermia is recommended for controlling ICP but is not recommended over normothermia for improving overall outcomes.
  • For hemodynamically stable patients with refractory ICP, high-dose barbiturate therapy is recommended.
  • Decompressive craniectomy (DC) is recommended for treating neurologic deterioration, herniation, or intracranial hypertension refractory to medical management.
  • Initiating early enteral nutritional support (within 72 hours from injury) is recommended for decreasing mortality and improving outcomes.
  • Corticosteroids are not recommended for ICP.