Appendix B: Management of Catastrophic Brain Injury

1. Disseminated Intravascular Coagulation (DIC)

Begin correcting any coagulation lab abnormalities (thrombocytopenia, increased INR) early, before clinical DIC.

2. Diabetes Insipidus (DI)

- If patient is normotensive, serum sodium > 150 and Urinary Output (UOP) > 600cc/hr, give 1-2 micrograms of DDAVP IVP (q 2-8 hours as needed)
- Replace UOP cc for cc with 1/2 NS q hour for UOP > 200 (example: for UOP of 1000cc replace with 800cc of 1/2 NS).
- If patient’s serum sodium > 150 and UOP > 300cc/hr, replace UOP cc for cc with 1/2 NS q hour for UOP > 200cc.
- If patient is hypotensive, then use protocol in Appendix A, and consider adding a vasopressin drip if DI is suspected.

Pitfalls: Assuming high UOP is from DI, but is really from diuretics and/or Mannitol. Replace diuretic fluid loss with NS or LR if hypotensive. (Another marker of DI: urine specific gravity < 1.005).

3. Tachycardia and Hypertension

This commonly occurs prior to complete herniation and should not be treated. Abrupt fluctuations in blood pressure during the period before and immediately after herniation are common. Aggressive treatment of hypertension will only further exacerbate the hypotension that may follow during the natural physiologic course of the herniation process.

4. Neurogenic Pulmonary Edema

This may occur and results in decreased PaO2; increase ventilator support as needed. With severe problems of oxygenation, utilize increased Positive End Expiratory Pressure (PEEP) and consider advanced ventilator modes such as Airway Pressure Release Ventilation (APRV) or VDR if available. Increasing PEEP, however, can decrease cerebral venous return and should be considered when managing neurogenic pulmonary edema. Similarly, APRV results in permissive hypercapnia, also detrimental to a head injured patient. Once neurogenic edema has been diagnosed, maintaining a low cardiac filling and limiting intravenous fluids to minimize pulmonary edema would be ideal, however, it must be done while balancing of needs of the other organ systems.

5. Hypokalemia and/or Hyperglycemia

Use sliding scales as needed.

6. T4 Protocol

Many patients have a T-3/T-4 deficiency and require additional thyroxin. Start patients on thyroxin protocol if thyroxine is available in patients with severe TBI that are continually hypotensive despite adequate fluid resuscitation and high dose pressors. (Appendix C: T-4 Replacement Protocol) Be aware that potassium will likely need to be aggressively replaced once thyroxin is started.

7. Cardiac Arrest

Follow ACLS code guidelines.