Resuscitation Strategies for Traumatic Brain Injury

Abstract

Purpose of Review: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality; however, little definitive evidence exists about most clinical management strategies. Here, we highlight important differences between two major guidelines, the 2016 Brain Trauma Foundation guidelines and the Lund Concept, along with recent pre-clinical and clinical data. Recent findings: While intracranial pressure (ICP) monitoring has been questioned, the majority of literature demonstrates benefit in severe TBI. The optimal cerebral perfusion pressure (CPP) and ICP are yet unknown, but likely as important is the concept of ICP burden. The evidence for anti-hypertensive therapy is strengthening. Decompressive craniectomy improves mortality, but at the cost of increased morbidity. Plasma-based resuscitation has demonstrated benefit in multiple pre-clinical TBI studies. Summary: The management of hemodynamics and intravascular volume are crucial in TBI. Based on recent evidence, ICP monitoring, anti-hypertensive therapy, minimal use of vasopressors/inotropes, and plasma resuscitation may improve outcomes.

Concomitant Traumatic Brain Injury and Hemorrhagic Shock: Outcomes Using the Spanish Trauma ICU Registry (RETRAUCI)

“…17 • Volume and type of resuscitation: while volume replacement has been the first measure taken in trauma patients with hypotension, current evidence suggest that enhanced volume resuscitation has no effect or can be even deleterious in TBI patients. 8,18 Here, the use of FFP with or without the addition of valproic acid 19 or resuscitation with fresh whole blood 16 are appealing strategies and have been associated with an improved expression of proteins essential for blood-brain barrier integrity 19 or neurological outcomes 16 in experimental models.…”

Use of Vasopressors Increases the Risk of Mortality in Severe Traumatic Brain Injury: A Nationwide Retrospective Cohort Study in Japan

“…This may also result in unwanted hemodynamic effects, such as intracranial hemorrhage, leading to increased mortality [28,29]. Additionally, vasopressors cause an array of adverse effects among other organs of the body [30,31]. Catecholamine surge after TBI can lead to peripheral insults induced by the release of proin ammatory substances and result in increased vascular permeability [30].…”

“…Additionally, vasopressors cause an array of adverse effects among other organs of the body [30,31]. Catecholamine surge after TBI can lead to peripheral insults induced by the release of proin ammatory substances and result in increased vascular permeability [30]. In this situation, the accentuated proin ammatory response could trigger the development of acute respiratory distress syndrome [31].…”

Traumatic Brain Injury—A Review of Intravenous Fluid Therapy

“…The BTF interventions are based on a set of evidencebased recommendations gleaned from a literature review of published studies, and the BTF guidelines do not make any recommendations about the use of any specific fluid type. The Lund Concept describes non-individualized, pre-emptive, ICP-regulating and perfusion-targeted therapy for manipulating transcapillary fluid dynamics using albumin (in addition to vasodilators and avoiding the use of vasopressors), but lacks strong evidence supporting the protocol (10,11). There are no clinical trials evaluating any fluid type for resuscitation from hemorrhagic shock in veterinary patients with TBI.…”