Primer on medical management of severe brain injury

OBJECTIVE: To review the current understanding of the medical management of severe brain injury. DATA SOURCE: The MEDLINE database, bibliographies of selected articles, and current English-language texts on the subject. STUDY SELECTION: Studies related to management of intracranial hypertension, traumatic brain injury, and brain edema. DATA EXTRACTION: All studies relevant to the subject under consideration were considered, with a focus on clinical studies in adults. DATA SYNTHESIS: Basic rules of resuscitation must apply, including adequate ventilation, appropriate fluid administration, and cardiovascular support. The control of intracranial pressure can be considered in three steps. The first step should be initial slight hyperventilation with a target PaCO2 of 35 mm Hg and cerebrospinal fluid drainage for intracranial pressure of >15-20 mm Hg. The second step should be mannitol or hypertonic saline and hyperventilation to target PaCO2 of 28-35 mm Hg. The third step should be barbiturate coma or decompressive craniectomy. Additional management issues, including seizure prophylaxis, sedation, nutritional support, use of hypothermia, and corticosteroids, are also discussed. CONCLUSIONS: Brain injury is frequently associated with the development of brain edema and the development of intracranial hypertension. However, with a coordinated, stepwise, and aggressive approach to management, focusing on control of intracranial pressure without adversely affecting cerebral perfusion pressure, outcomes can be good.