There is a delicate balance when sedating patients with TBI. When transferring casualties to a neurosurgical capability for initial assessment, avoid long-lasting sedation or paralysis as this impedes the ability to evaluate the patient. However, medication selection should not override the need to safely transport the casualty.
Despite controversy on the use of invasive monitoring to measure ICP, treatment of known or suspected intracranial hypertension remains a cornerstone of therapy in patients with severe brain injury.42
Intracranial hypertension should be suspected based on certain clinical criteria if no CT scan or intracranial monitor is available. These criteria include:
If treatment for intracranial hypertension is indicated prior to arrival to a neurosurgical capability, initiate hyperosmotic therapy with one of the following:
1. Hypertonic Saline42,43 (Appendix B)
2. Mannitol
Avoid Mannitol during the initial resuscitation period when ongoing bleeding has not been ruled out and in hypotensive casualties (or any casualty with the risk of bleeding).
Consider using Mannitol only if there is no availability of hypertonic saline and there is a significant concern for imminent herniation as evidenced by signs of intracranial hypertension described above.
ANTIEPILEPTIC MEDICATIONS AND SEIZURES
Seizures are common after severe brain trauma. Administer seizure prophylaxis to avoid the hemodynamic changes and increased cerebral metabolic activity caused by seizures. Seizure medications help prevent early post-traumatic seizures, but do not prevent all seizures. Up to 25% of patients with severe TBI will have seizures even with prophylactic treatment. Fifty percent of seizures may be non-convulsive in nature. Patients with subdural hematoma, neurosurgical procedure, or penetrating brain injury are at the highest risk of seizures. Post-traumatic seizures have been shown to increase morbidity and mortality after trauma.44-47
Lorazepam 1-2mg IV or Midazolam 5-10mg IV. Lorazepam is preferred. If no IV access, Midazolam IM is as effective as Lorazepam IV