Treatment

The clinical management of catastrophic brain injury is focused on hemodynamic stabilization. This consists of three aspects:

1. Early identification of the severity of injury, as severity of the TBI correlates with deficiencies in the pituitary adrenal axis, leading to hemodynamic instability.25

2. Intensive care management to achieve hemodynamic stability based on degree of TBI and associated injuries.26

3. Resuscitation with fluids and blood products, early use of vasopressors and consideration for endocrine/hormone therapy in patients with refractory hemodynamic instability.

Vasopressors such as norepinephrine should be utilized if the mean arterial pressure (MAP) remains less than 70 mmHg despite adequate fluid resuscitation. (See Appendix A.) In patients whom Diabetes Insipidus (DI) is suspected, consider adding a vasopressin drip to norepinephrine after initial treatment with DDAVP. (See Appendix A and Appendix B treatment of DI). In casualties with catastrophic head injury who require more than a single vasopressor to maintain a systolic blood pressure of 100 mmHg or have evidence of DI, strong consideration should be given for addressing the endocrine abnormalities associated with these injuries that can contribute to ongoing hemodynamic instability. (See Appendix B.)25-29 Adjuncts shown to assist with hemodynamic stability include stress dose steroids, IV insulin, and replacement of thyroid hormone.

These adjuncts are:

1. 1 ampule 50% dextrose IV

2. 2 g solumedrol IV

3. 20 units regular insulin IV

4. 20 micrograms of thyroid hormone (T4) IV, if available

This is given as an initial bolus followed by a continuous infusion of 10 mcg/hr of T4, if it is available.

An appropriately aggressive approach should also stress early identification and management of catastrophic brain injury-related complications such as:

1. Disseminated intravascular coagulation (DIC)

2. Diabetes Insipidus (DI)

3. Neurogenic pulmonary edema (NPE)

4. Hypothermia

5. Cardiac arrhythmias

See Appendix C for management points on each.