Neurocritical Care
Seizure prophylaxis
Recommended as an option for prevention of early posttraumatic seizures (first 7 days after event)
Phenytoin/fosphenytoin is the most commonly recommended agent (because of support for use
from prospective clinical trials) (N Engl J Med 1990;323:497-502).
Levetiracetam is also commonly used, despite a paucity of data (monitor for pronounced behavioral
adverse effects in patients with neurologic injury).
| d. | Valproic acid is as effective as phenytoin, but a trend toward increased mortality was observed in |
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a prospective clinical trial; thus, it is usually avoided if possible (J Neurosurg 1999;91:593-600).
Use of anticonvulsants for prevention of late seizures (after 7 days) has not been proven effective
(not recommended).
CPP = mean arterial pressure (MAP) minus ICP.
Surrogate for global cerebral perfusion
Recommended goal is 60–70 mm Hg.
| d. | Ideal CPP may have interpatient variability because of the patient’s medical history and unique |
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characteristics of the TBI.
Patients with refractory elevations in ICP or who have a history of poorly treated hypertension
(right shift of autoregulatory curve) may require a higher CPP.
Fluid resuscitation with or without vasopressor therapy
Norepinephrine or phenylephrine are the preferred vasopressors for this indication.
Supportive care – Venous thromboembolism (VTE) prophylaxis
Patients with a TBI have an increased risk of VTE because of:
TBI-related coagulopathy
ii.
Delay in initiation of pharmacologic VTE prophylaxis
iii.
Immobility
iv.
Concomitant injuries (in polytrauma)
Mechanical prophylaxis should be initiated as soon as possible.
Pharmacologic prophylaxis should be initiated after intracranial bleeding is stabilized.
Typically, 24–48 hours after event
ii.
May depend on coagulopathy on admission, extension of bleeding on CT scan, and other
factors
iii.
Unfractionated heparin (every 8 hours) or low-molecular-weight heparin may be used for
pharmacologic prophylaxis. In patients with normal renal function, low-molecular-weight
heparin is preferred in those with polytrauma, particularly long bone or pelvic fractures.
Initiating nutrition support within 48 hours improves immune competence and may improve neurologic
particularly in those with an elevated ICP (causes decreased gastric motility). Postpyloric feeding
access should be established as soon as possible.
Metabolic needs are elevated after a TBI (typically proportional to the severity of injury).
Patients with a TBI typically require 120%–160% of basal metabolic needs.
Metabolic cart/direct calorimetry can be used to better evaluate caloric needs.
Prevention of Stress-Related Mucosal Bleeding
Patients with a TBI have an increased risk of stress-related mucosal bleeding.
Hypotension associated with a TBI or trauma
Hypersecretion of acid associated with neurologic injury (Cushing ulcers)