Moderate-to-severe traumatic brain injury - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:34Z

Strip excess bold

← Older revision		Revision as of 09:26, 22 March 2026
Line 80:		Line 80:
	*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])		*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])
	*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>		*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>
	**Indication: [[GCS]] ≤ 12 ~~'''~~OR~~'''~~ any intracranial bleeding on CT scan ~~'''~~AND~~'''~~ ≤ 3 hours since time of injury		**Indication: [[GCS]] ≤ 12 OR any intracranial bleeding on CT scan AND ≤ 3 hours since time of injury
	**Loading dose 1 g over 10 min; followed by maintenance dose of 1 g over 8 hrs		**Loading dose 1 g over 10 min; followed by maintenance dose of 1 g over 8 hrs
	**NNT = 76.9		**NNT = 76.9
Line 111:		Line 111:
	**'''Pre-treatment:''' No clear benefit to use of lidocaine to blunt reflex sympathetic response to laryngoscopy<ref>Butler J, Jackson R, Mackway-Jones K. Lignocaine premedication before rapid sequence induction in head injuries. Emergency medicine journal. 2002.</ref>.		**'''Pre-treatment:''' No clear benefit to use of lidocaine to blunt reflex sympathetic response to laryngoscopy<ref>Butler J, Jackson R, Mackway-Jones K. Lignocaine premedication before rapid sequence induction in head injuries. Emergency medicine journal. 2002.</ref>.
	***Short acting [[opioids]] can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.		***Short acting [[opioids]] can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.
	**~~'''~~Induction:~~'''~~ Selection of induction agent remains controversial:		**Induction: Selection of induction agent remains controversial:
	***[[Etomidate]] is well-studied with a stable hemodynamic profile		***[[Etomidate]] is well-studied with a stable hemodynamic profile
	***[[Ketamine]] which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.		***[[Ketamine]] which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.

Rossdonaldson1: /* Disposition */

2025-02-26T18:12:03Z

Disposition

← Older revision		Revision as of 18:12, 26 February 2025
Line 141:		Line 141:

	==Disposition==		==Disposition==
	*Generally ~~warrant~~ admission to a surgical intensive care unit.		*Generally warrants admission to surgical intensive care unit.

	==See Also==		==See Also==

Rossdonaldson1: /* Disposition */

2025-02-26T18:11:21Z

Disposition

← Older revision		Revision as of 18:11, 26 February 2025
Line 141:		Line 141:

	==Disposition==		==Disposition==
	Generally warrant admission to a surgical intensive care unit.		*Generally warrant admission to a surgical intensive care unit.

	==See Also==		==See Also==

Rossdonaldson1: /* Main goals in management */

2019-10-22T19:25:49Z

Main goals in management

← Older revision		Revision as of 19:25, 22 October 2019
Line 81:		Line 81:
	*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>		*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>
	**Indication: [[GCS]] ≤ 12 '''OR''' any intracranial bleeding on CT scan '''AND''' ≤ 3 hours since time of injury		**Indication: [[GCS]] ≤ 12 '''OR''' any intracranial bleeding on CT scan '''AND''' ≤ 3 hours since time of injury
	**Loading dose 1 g over 10 min		**Loading dose 1 g over 10 min; followed by maintenance dose of 1 g over 8 hrs
	**Followed by maintenance dose of 1 g over 8 hrs		**NNT = 76.9

	===Critical aspects===		===Critical aspects===

Rossdonaldson1: /* Main goals in management */

2019-10-22T19:24:25Z

Main goals in management

← Older revision		Revision as of 19:24, 22 October 2019
Line 80:		Line 80:
	*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])		*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])
	*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>		*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>
	**Indication: [[GCS]] ≤ 12 '''OR''' any intracranial bleeding on CT scan		**Indication: [[GCS]] ≤ 12 '''OR''' any intracranial bleeding on CT scan '''AND''' ≤ 3 hours since time of injury
	**Loading dose 1 g over 10 min		**Loading dose 1 g over 10 min
	**Followed by maintenance dose of 1 g over 8 hrs		**Followed by maintenance dose of 1 g over 8 hrs

Rossdonaldson1: /* Main goals in management */

2019-10-22T19:23:27Z

Main goals in management

← Older revision		Revision as of 19:23, 22 October 2019
Line 79:		Line 79:
	*Prevent [[hypotension]]		*Prevent [[hypotension]]
	*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])		*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])
	*[[Tranexemic acid]] ~~"reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding"~~<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>		*[[Tranexemic acid]]<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>
			**Indication: [[GCS]] ≤ 12 '''OR''' any intracranial bleeding on CT scan
	**Loading dose 1 g over 10 min		**Loading dose 1 g over 10 min
	**Followed by maintenance dose of 1 g over 8 hrs		**Followed by maintenance dose of 1 g over 8 hrs

Hoxbox: /* Main goals in management */

2019-10-16T15:14:51Z

Main goals in management

← Older revision		Revision as of 15:14, 16 October 2019
Line 79:		Line 79:
	*Prevent [[hypotension]]		*Prevent [[hypotension]]
	*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])		*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])
	*[[Tranexemic acid]] ~~may reduce progressive ICH~~<ref>~~Yutthakasemsunt S et al~~. ~~Tranexamic Acid for Patients With Traumatic Brain Injury. BMC Emerg Med. 2013;13~~.</ref>		*[[Tranexemic acid]] "reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding"<ref>[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext CRASH-3 Trial]</ref>
	**Loading dose 1 g over 10 min		**Loading dose 1 g over 10 min
	**Followed by maintenance dose of 1 g over 8 hrs		**Followed by maintenance dose of 1 g over 8 hrs

ClaireLewis: /* Management of Impending Herniation */

2019-10-03T04:00:50Z

Management of Impending Herniation

← Older revision		Revision as of 04:00, 3 October 2019
Line 125:		Line 125:

	===Management of Impending Herniation===		===Management of Impending Herniation===
	Hyperosmolar therapy is indicated for patients with objective [[~~raised~~ ICP\|elevations of intracranial pressure]] or signs of impending or ongoing herniation.		Hyperosmolar therapy is indicated for patients with objective [[elevated ICP\|elevations of intracranial pressure]] or signs of impending or ongoing herniation.
	*Both [[hypertonic saline]] and [[mannitol]] are effective at reducing intracranial pressure<ref>Sakellaridis N, Pavlou E, Karatzas S, et al. Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries. J Neurosurg. 2011;114(2):545–548. doi:10.3171/2010.5.JNS091685.</ref>.		*Both [[hypertonic saline]] and [[mannitol]] are effective at reducing intracranial pressure<ref>Sakellaridis N, Pavlou E, Karatzas S, et al. Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries. J Neurosurg. 2011;114(2):545–548. doi:10.3171/2010.5.JNS091685.</ref>.
	*Meta-analyses of limited and variable data suggest benefit towards hypertonic saline<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Critical Care Medicine. 2011;39(3):554–559. doi:10.1097/CCM.0b013e318206b9be.</ref>.		*Meta-analyses of limited and variable data suggest benefit towards hypertonic saline<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Critical Care Medicine. 2011;39(3):554–559. doi:10.1097/CCM.0b013e318206b9be.</ref>.

ClaireLewis: /* Airway */

2019-10-03T04:00:35Z

Airway

← Older revision		Revision as of 04:00, 3 October 2019
Line 111:		Line 111:
	***Short acting [[opioids]] can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.		***Short acting [[opioids]] can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.
	**'''Induction:''' Selection of induction agent remains controversial:		**'''Induction:''' Selection of induction agent remains controversial:
	**[[Etomidate]] is well-studied with a stable hemodynamic profile		***[[Etomidate]] is well-studied with a stable hemodynamic profile
	**[[Ketamine]] which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.		***[[Ketamine]] which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.
	**'''Paralysis:''' No apparent benefit to the addition of a defasciculating dose of non-depolarizing neuromuscular blocking agent (to prevent transient elevation of intracranial pressure associated with widespread muscle fasciculation)<ref>Paralysis:Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373–375.</ref>.		**'''Paralysis:''' No apparent benefit to the addition of a defasciculating dose of non-depolarizing neuromuscular blocking agent (to prevent transient elevation of intracranial pressure associated with widespread muscle fasciculation)<ref>Paralysis:Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373–375.</ref>.

ClaireLewis at 04:00, 3 October 2019

2019-10-03T04:00:08Z

← Older revision		Revision as of 04:00, 3 October 2019
Line 15:		Line 15:
	===Physical Examination===		===Physical Examination===
	*Calculate [[GCS]]		*Calculate [[GCS]]
	*Pupils: may identify herniation syndromes		*Pupils: may identify [[herniation Syndrome\|herniation syndromes]]
	*Motor		*Motor
	**Focus on symmetry as hemiparesis may suggest herniation syndrome		**Focus on symmetry as [[weakness\|hemiparesis]] may suggest herniation syndrome
	**Elicit movement with noxious stimuli in non-cooperative patients		**Elicit movement with noxious stimuli in non-cooperative patients
	**Note voluntary or purposeful movement (crossing the midline, approaching the stimulus, pushing the examiner's hand away)		**Note voluntary or purposeful movement (crossing the midline, approaching the stimulus, pushing the examiner's hand away)
	*Cranial Nerves		*[[Cranial Nerves]]
	**Assessable cranial nerves: pupils (III), corneal (V, VII), gag (IX, X), VOR (VII, VI)		**Assessable cranial nerves: pupils (III), corneal (V, VII), gag (IX, X), VOR (VII, VI)
	*Reflexes		*Reflexes
Line 28:		Line 28:
	''More common in children than adults''		''More common in children than adults''
	:Triad of:		:Triad of:
	#Hypertension		#[[Hypertension]]
	#Bradycardia		#[[Bradycardia]]
	#Respiratory irregularity		#Respiratory irregularity

Line 43:		Line 43:
	**Face and/or orbit CT		**Face and/or orbit CT
	**C-spine CT		**C-spine CT
			*Blood glucose ([[hypoglycemia]] increases risk of secondary injury and also lowers [[seizure]] threshold)
			*CBC
	*Pertinent labs		**Consideration for [[pRBCs\|transfusion]] with Hb < 7 mg/dL
	*Blood glucose		**Consideration of transfusing for [[thrombocytopenia]] if evidence of [[ICH]]
	*~~Venous blood~~
	*~~Hemoglobin assessment with consideration~~ for transfusion with Hb < 7 mg/dL
	*PT/INR/PTT		*PT/INR/PTT
	*Electrolytes		*Electrolytes
	**[[Hyponatremia]], hypomagnesemia, and hypophosphatemia may lower the seizure threshold		**[[Hyponatremia]], [[hypomagnesemia]], and [[hypophosphatemia]] may lower the seizure threshold
	*Miscellaneous labs		*Miscellaneous labs
	**Beta-2 transferrin for CSF leak, needs 0.5 cc of fluid<ref>Arup Laboratories. https://arupconsult.com/content/cerebrospinal-fluid-csf-leak-beta-2-transferrin.</ref>		**Beta-2 transferrin for CSF leak, needs 0.5 cc of fluid<ref>Arup Laboratories. https://arupconsult.com/content/cerebrospinal-fluid-csf-leak-beta-2-transferrin.</ref>
Line 75:		Line 73:
	*Maintain Cerebral Perfusion Pressure (CPP) > 70 mmHg		*Maintain Cerebral Perfusion Pressure (CPP) > 70 mmHg
	*Optimize cerebral oxygenation and blood flow		*Optimize cerebral oxygenation and blood flow

	*Monitor for increased ICP		*Monitor for increased ICP
	*Monitor for [[Brain herniation syndromes\|herniation]]		*Monitor for [[Brain herniation syndromes\|herniation]]
	*Maintain PaO2 > 60 mmHg		*Maintain PaO2 > 60 mmHg
	*Prevent hyperthermia		*Prevent [[hyperthermia]]
	*Prevent hypotension		*Prevent [[hypotension]]
	*Correct coagulopathy (FFP, vitamin K, PCC, desmopressin)		*Correct [[coagulopathy]] ([[FFP]], [[vitamin K]], [[PCC]], [[desmopressin]])
	*[[Tranexemic acid]] may reduce progressive ICH<ref>Yutthakasemsunt S et al. Tranexamic Acid for Patients With Traumatic Brain Injury. BMC Emerg Med. 2013;13.</ref>		*[[Tranexemic acid]] may reduce progressive ICH<ref>Yutthakasemsunt S et al. Tranexamic Acid for Patients With Traumatic Brain Injury. BMC Emerg Med. 2013;13.</ref>
	**Loading dose 1 g over 10 min		**Loading dose 1 g over 10 min
Line 111:		Line 108:
	*Early [[Rapid Sequence Intubation\|endotracheal intubation]] is indicated.		*Early [[Rapid Sequence Intubation\|endotracheal intubation]] is indicated.
	**'''Pre-oxygenation:''' Hyperoxia in TBI can be harmful<ref>Brenner M, Stein D, Hu P, Kufera J, Wooford M, Scalea T. Association Between Early Hyperoxia and Worse Outcomes After Traumatic Brain Injury. Arch Surg. 2012;147(11):1042–5. doi:10.1001/archsurg.2012.1560.</ref>, however it can be assumed that resumption of targeting normoxemia immediately after securing airway control outweighs the potential harm of hypoxia during intubation (which can often be challenging in these settings due to maxillofacial trauma and maintenance of cervical spine precautions).		**'''Pre-oxygenation:''' Hyperoxia in TBI can be harmful<ref>Brenner M, Stein D, Hu P, Kufera J, Wooford M, Scalea T. Association Between Early Hyperoxia and Worse Outcomes After Traumatic Brain Injury. Arch Surg. 2012;147(11):1042–5. doi:10.1001/archsurg.2012.1560.</ref>, however it can be assumed that resumption of targeting normoxemia immediately after securing airway control outweighs the potential harm of hypoxia during intubation (which can often be challenging in these settings due to maxillofacial trauma and maintenance of cervical spine precautions).
	**'''Pre-treatment:''' No clear benefit to use of lidocaine to blunt reflex sympathetic response to laryngoscopy<ref>Butler J, Jackson R, Mackway-Jones K. Lignocaine premedication before rapid sequence induction in head injuries. Emergency medicine journal. 2002.</ref>. Short acting opioids can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.		**'''Pre-treatment:''' No clear benefit to use of lidocaine to blunt reflex sympathetic response to laryngoscopy<ref>Butler J, Jackson R, Mackway-Jones K. Lignocaine premedication before rapid sequence induction in head injuries. Emergency medicine journal. 2002.</ref>.
	**'''Induction:''' Selection of induction agent remains controversial. Etomidate is well-studied with a stable hemodynamic profile. Ketamine which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.		***Short acting [[opioids]] can be considered in hemodynamically stable patients<ref>Chung KS, Sinatra RS, Halevy JD, Paige D, Silverman DG. A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction. Can J Anaesth. 1992;39(8):774–779. doi:10.1007/BF03008287.</ref>.
			**'''Induction:''' Selection of induction agent remains controversial:
			**[[Etomidate]] is well-studied with a stable hemodynamic profile
			**[[Ketamine]] which has shown promise in some trials due to its hemodynamic profile (commonly increased MAP and subsequently CPP) without previously-cited deleterious effects on ICP and may be the agent of choice for patients with hemodynamic compromise<ref>Sehdev RS, Symmons DA, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas. 2006;18(1):37–44. doi:10.1111/j.1742-6723.2006.00802.x.</ref> <ref>Hughes S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: is ketamine a viable induction agent for the trauma patient with potential brain injury. Emerg Med J. 2011;28(12):1076–1077. doi:10.1136/emermed-2011-200891.</ref>.
	**'''Paralysis:''' No apparent benefit to the addition of a defasciculating dose of non-depolarizing neuromuscular blocking agent (to prevent transient elevation of intracranial pressure associated with widespread muscle fasciculation)<ref>Paralysis:Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373–375.</ref>.		**'''Paralysis:''' No apparent benefit to the addition of a defasciculating dose of non-depolarizing neuromuscular blocking agent (to prevent transient elevation of intracranial pressure associated with widespread muscle fasciculation)<ref>Paralysis:Clancy M, Halford S, Walls R, Murphy M. In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review. Emerg Med J. 2001;18(5):373–375.</ref>.

Line 119:		Line 119:

	===Circulation===		===Circulation===
	*Avoid hypotension (SBP <90mmHg)		*Avoid [[hypotension]] (SBP <90mmHg)
	*Fluid resuscitation with isotonic saline, and vasopressors if refractory.		*[[IVF\|Fluid]] resuscitation with isotonic saline, and vasopressors if refractory.
	*Albumin should be avoided<ref>SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–884. doi:10.1056/NEJMoa067514.</ref>.		*Albumin should be avoided<ref>SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–884. doi:10.1056/NEJMoa067514.</ref>.
	*~~There is no~~ apparent benefit to the initial administration of hypertonic saline<ref>Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004;291(11):1350–1357. doi:10.1001/jama.291.11.1350.</ref> <ref>Bulger EM, May S, Brasel KJ, et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA. 2010;304(13):1455–1464. doi:10.1001/jama.2010.1405.</ref>.		*No apparent benefit to the initial administration of [[hypertonic saline]]<ref>Cooper DJ, Myles PS, McDermott FT, et al. Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury: a randomized controlled trial. JAMA. 2004;291(11):1350–1357. doi:10.1001/jama.291.11.1350.</ref> <ref>Bulger EM, May S, Brasel KJ, et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA. 2010;304(13):1455–1464. doi:10.1001/jama.2010.1405.</ref>.

	===Management of Impending Herniation===		===Management of Impending Herniation===
	Hyperosmolar therapy is indicated for patients with objective elevations of intracranial pressure or signs of impending or ongoing herniation.		Hyperosmolar therapy is indicated for patients with objective [[raised ICP\|elevations of intracranial pressure]] or signs of impending or ongoing herniation.
	*Both [[hypertonic saline]] and [[mannitol]] are effective at reducing intracranial pressure<ref>Sakellaridis N, Pavlou E, Karatzas S, et al. Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries. J Neurosurg. 2011;114(2):545–548. doi:10.3171/2010.5.JNS091685.</ref>.		*Both [[hypertonic saline]] and [[mannitol]] are effective at reducing intracranial pressure<ref>Sakellaridis N, Pavlou E, Karatzas S, et al. Comparison of mannitol and hypertonic saline in the treatment of severe brain injuries. J Neurosurg. 2011;114(2):545–548. doi:10.3171/2010.5.JNS091685.</ref>.
	*Meta-analyses of limited and variable data suggest benefit towards hypertonic saline<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Critical Care Medicine. 2011;39(3):554–559. doi:10.1097/CCM.0b013e318206b9be.</ref>.		*Meta-analyses of limited and variable data suggest benefit towards hypertonic saline<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Critical Care Medicine. 2011;39(3):554–559. doi:10.1097/CCM.0b013e318206b9be.</ref>.