Non-operative management of intracranial hemorrhage requires neurosurgical consultation, repeat imaging until CT scan is stable, and serial exams.
Surgical intervention may be indicated in the management of patients with severe brain injury. This includes operative care such as evacuation of space-occupying hematomas via craniectomy or craniotomy as well as placement of multimodal intracranial monitors.
INTRACRANIAL PRESSURE MONITORING
Management of severe TBI patients using information from ICP monitoring is recommended. Although long-term outcomes have not been shown to be improved with ICP monitoring, there is evidence that in-hospital and two-week post-injury mortality is improved.22 Additionally, the military trauma system may require multiple patient movements and handoffs that decrease the ability to follow neurologic exams. Therefore, ICP monitoring may detect a deterioration that would normally be detected on serial neurologic exam in a stable ICU environment.
ICP monitoring should be considered in all salvageable patients with:
Additionally, a low threshold for ICP monitoring should be maintained in severe TBI patients with any abnormal head CT and inability to follow serial neurologic exam such as during other surgical interventions required early after injury, long-range evacuation of intubated patients, etc.
Options for ICP monitoring:25
If using antibiotic impregnated ventriculostomy, then no IV prophylactic antibiotics required. Otherwise, Ancef 1gm IV TID may be prescribed while ventriculostomy is in place (neurosurgeon’s discretion). The goal ICP is <22 mmHg.25
Cerebral perfusion pressure is defined as: CPP = MAP-ICP. 22 The goal cerebral perfusion pressure (CPP) is between 60-70 mmHg when the autoregulator status of the patient is uncertain.
Brain Tissue Oxygen Monitoring
Note This monitoring capability may not be readily available, parameters have been outlined here in case these monitoring strategies are applicable in the future.