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Review
. 2022 Aug 16;11(16):4790.
doi: 10.3390/jcm11164790.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Charikleia S Vrettou  1 , Spyros D Mentzelopoulos  1
Affiliations
Review

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Charikleia S Vrettou et al. J Clin Med. .

Abstract

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Keywords: brain trauma; intracranial hypertension; neuromonitoring.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Treatment modalities included in the tiered approach for the management of intracranial hypertension. ICU: intensive care unit; ETCO2: end-tidal carbon dioxide partial pressure; ICP: intracranial pressure; SpO2: oxygen saturation; CPP: cerebral perfusion pressure; Hb: hemoglobin concentration; SerOsm: serum osmolality; CSF: cerebrospinal fluid; EVD: external ventricular drain; EEG: electroencephalography; NMB: neuromuscular blocker; MAP: mean arterial pressure. * Propofol and midazolam are the most commonly used anesthetic agents. Morphine, fentanyl, sulfentanil and remifentanil are the most commonly used analgesics [20]. ** Non-depolarizing agents are considered as safer than succinylcholine [21].
Figure 2
Figure 2
Definition, causes, and management of critical neuroworsening. mGCS: motor Glasgow Coma Score; PLR: pupillary light reflex; SOL: space-occupying lesion; ICP: intracranial pressure; HOT: hyperosmolar therapy.
Figure 3
Figure 3
A simplified version of the three-tier therapy protocol proposed for the treatment of suspected intracranial hypertension when intracranial pressure monitoring is not employed. Decisions on escalation and de-escalation are based on serial clinical examination and computerized tomography imaging. MAP: mean arterial pressure; PaCO2: partial arterial pressure of carbon dioxide.
See this image and copyright information in PMC

References

    1. Menon D.K., Schwab K., Wright D.W., Maas A.I. Position Statement: Definition of Traumatic Brain Injury. Arch. Phys. Med. Rehabil. 2010;91:1637–1640. doi: 10.1016/j.apmr.2010.05.017. - DOI - PubMed
    1. Clark D., Joannides A., Adeleye A.O., Bajamal A.H., Bashford T., Biluts H., Budohoski K., Ercole A., Fernández-Méndez R., Figaji A., et al. Casemix, Management, and Mortality of Patients Receiving Emergency Neurosurgery for Traumatic Brain Injury in the Global Neurotrauma Outcomes Study: A Prospective Observational Cohort Study. Lancet Neurol. 2022;21:438–449. doi: 10.1016/S1474-4422(22)00037-0. - DOI - PubMed
    1. Menon D.K., Ercole A. Handbook of Clinical Neurology. Volume 140. Elsevier B.V.; Amsterdam, The Netherlands: 2017. Critical Care Management of Traumatic Brain Injury; pp. 239–274. - PubMed
    1. Maas A.I.R., Menon D.K., David Adelson P.D., Andelic N., Bell M.J., Belli A., Bragge P., Brazinova A., Büki A., Chesnut R.M., et al. Traumatic Brain Injury: Integrated Approaches to Improve Prevention, Clinical Care, and Research. Lancet Neurol. 2017;16:987–1048. doi: 10.1016/S1474-4422(17)30371-X. - DOI - PubMed
    1. Vik A., Nag T., Fredriksli O.A., Skandsen T., Moen K.G., Schirmer-Mikalsen K., Manley G.T. Relationship of “Dose” of Intracranial Hypertension to Outcome in Severe Traumatic Brain Injury. J. Neurosurg. 2008;109:678–684. doi: 10.3171/JNS/2008/109/10/0678. - DOI - PubMed

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