This is the current release of the guideline.

Severe traumatic brain injury

Adults with a brain injury incurred by a traumatic mechanism of injury with a resultant level of consciousness categorized by a Glasgow Coma Scale score of 8 or lower

A computerized search of Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) was performed using the names of specific nursing interventions with and without intracranial pressure (ICP) or cerebral perfusion pressure (CPP) as keywords. The search was primarily restricted to works in English published in 2000–2008 in which all or part of the sample included adults with severe traumatic brain injury (TBI). Few studies were found on certain nursing interventions. In these instances, the search was expanded to include the years 1997–1999 for relevant works. The reference lists of identified articles also were searched for additional studies.

Not stated

Levels of Evidence

Class I: Randomized controlled trial without significant limitations or meta-analysis

Class II: Randomized controlled trial with important limitations (e.g., methodological flaws, inconsistent results); observational study (e.g., cohort, case control)

Class III: Qualitative study, case study, or series

Class IV: Evidence from reports of expert committees and/or expert opinion of the guideline panel, standards of care, and clinical protocols that have been identified

Two neurotrauma nursing experts determined the level of evidence for each study included under every recommendation, summarizing the level of evidence for each recommendation.

The Clinical Practice Guidelines and recommendations for practice are established based upon the evaluation of the available evidence.

The guidelines address the following research questions:

• What nursing interventions maintain or decrease ICP in patients with severe TBI?
• What nursing interventions maintain adequate CPP or increase CPP in patients with severe TBI?
• What monitoring modalities can successfully guide nursing interventions in severe TBI?
• What nursing interventions prevent DVT in patients with severe TBI?
• What nursing interventions promote adequate nutrition in patients with severe TBI?
• What nursing interventions prevent hyperglycemia in patients with severe TBI?
• What nursing interventions prevent seizures in patients with severe TBI?

Levels of Recommendation

Level 1: Recommendations are supported by class I evidence.

Level 2: Recommendations are supported by class II evidence.

Level 3: Recommendations are supported by class III and class IV evidence.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Blinded external peer review was performed using established criteria for evaluation.

The levels of evidence (Class I-IV) supporting the recommendations and levels of recommendation (Level 1-3) are defined at the end of the "Major Recommendations" field.

Recommendations (see algorithm in Figure 1 of the original guideline document)

Maintaining or Decreasing Intracranial Pressure (ICP)

1. Maintaining ICP at less than 20 mm Hg improves outcomes. (Level 1)
2. Draining cerebrospinal fluid (CSF) decreases ICP. (Level 2)
3. Do not induce hyperventilation to decrease ICP. (Level 2)
4. Administering sedation prevents ICP increases. (Level 2)
5. Administering mannitol is effective in decreasing ICP. (Level 2)

   The diuretic effect of mannitol can cause increased sodium and serum osmolarity levels, and should be monitored at regular intervals.

6. Elevate the head of the bed (HOB) 30 degrees to maintain or decrease ICP. (Level 2)
7. Removing or loosening rigid cervical collars may decrease ICP. (Level 3)
8. Administering intensive insulin therapy may reduce ICP. (Level 3)
9. Maintaining normothermia may prevent ICP increases. (Level 2)

Controversial Treatments for Refractory Intracranial Hypertension

1. Inducing moderate hypothermia may decrease ICP in refractory intracranial hypertension. (Level 2)
2. Administering hypertonic saline may decrease ICP in refractory intracranial hypertension. (Level 3)

   Sodium levels and urine output require close monitoring.

3. Administering high-dose barbiturates may decrease ICP in refractory intracranial hypertension. (Level 3)

   When using this treatment paradigm, continuous electroencephalogram (EEG) monitoring or a bispectral index monitor should be used to guide this dose-dependent therapy. Hemodynamic stability must be achieved before instituting high-dose barbiturates.

4. Hyperventilation rapidly decreases ICP in emergent intracranial hypertension. (Level 3)

   In the event this ICP therapy technique is used, advanced monitoring techniques such as jugular venous oxygen saturation or brain tissue oxygenation should be considered to ensure adequate substrate delivery to the vulnerable brain.

Maintaining Adequate Cerebral Perfusion Pressure (CPP) or Increasing CPP

1. Maintaining CPP between 50–70 mm Hg optimizes cerebral perfusion. (Level 2)

   A general threshold of 60 mm Hg may be appropriate with further fine-tuning based on multimodality monitoring.

2. Administering norepinephrine may maintain adequate CPP or increase CPP. (Level 3)

   Catecholamines can cause negative side effects such as skin ulcers and decreased blood flow to renal and mesenteric circulations, especially with prolonged use at high doses.

3. Elevating the HOB 0–30 degrees may maintain adequate CPP or increase CPP. (Level 3)
4. CSF drainage may be an effective treatment for low CPP. (Level 3)

Monitoring Modalities

1. Continuous ICP monitoring and display successfully guide nursing interventions. (Level 2)
2. Continuous CCP monitoring and display may successfully guide nursing interventions. (Level 3)
3. Continuous brain tissue oxygen (PbtO₂) monitoring and display may successfully guide nursing interventions. (Level 3)
4. Monitoring and displaying brain temperature may successfully guide nursing interventions. (Level 3)

Preventing Deep Venous Thrombosis (DVT)

1. Pharmacologic treatment may be safe for DVT prophylaxis. (Level 3)
2. Applying mechanical prophylaxis on admission may prevent DVT in patients who cannot receive immediate pharmacologic prophylaxis due to risk of bleeding (Level 3)

Adequate Nutrition

1. Initiating adequate nutrition within 72 hours of injury may improve outcomes. (Level 3)
2. Providing continuous intragastric feeding may improve tolerance. (Level 3)
3. Prokinetic agents have shown no effect on feeding tolerance. (Level 2)

Glycemic Control

1. Administering intensive insulin therapy for elevated serum glucose (greater than 110 mg/dL) can improve outcomes (Level 2).

   Subcutaneous insulin administration has been shown to be unsafe and less effective than intravenous insulin administration in critically ill patients.

Preventing Seizures

1. Administering antiepileptic drugs decreases the incidence of early posttraumatic seizures. (Level 2)

   Chronic prophylaxis should be avoided.

2. Electroencephalogram (EEG) technology may help to identify patients at risk for seizures. (Level 3)

Definitions:

Levels of Evidence Supporting the Recommendations

Class I: Randomized controlled trial without significant limitations or meta-analysis

Class II: Randomized controlled trial with important limitations (e.g., methodological flaws, inconsistent results); observational study (e.g., cohort, case control)

Class III: Qualitative study, case study, or series

Class IV: Evidence from reports of expert committees and/or expert opinion of the guideline panel, standards of care, and clinical protocols that have been identified

Levels of Recommendation (based upon evaluation of the available evidence)

Level 1: Recommendations are supported by class I evidence.

Level 2: Recommendations are supported by class II evidence.

Level 3: Recommendations are supported by class III and class IV evidence.

The Treatment Algorithm: Clinical Practice Guidelines for the Nursing Management of Adults with Severe Traumatic Brain Injury is provided in the original guideline document.

The type of supporting evidence is identified and graded for all recommendations (see the "Major Recommendations" field).

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Association of Neuroscience Nurses

Defense and Veterans Brain Injury Center

Not stated

Content Authors: Laura Mcilvoy, PhD, RN, CCRN, CNRN; Kimberly Meyer, MSN, CNRN, ARNP

The American Association of Neuroscience Nurses (AANN) requires that all planners, teachers, and authors involved in CNE make full disclosure indicating whether the individual and/or his/her family have any relevant financial relationships, now or within the 12 months preceding this event, with a commercial interest (e.g. pharmaceutical companies, biomedical device manufacturers, and/or corporations) whose products or services are discussed in the continuing education activity content over which the individual has control. All presenters participating in the AANN sponsored programs must complete this form and return it as indicated. All information disclosed is printed in the program materials.

The authors state no potential conflicts of interest.

This is the current release of the guideline.

Electronic copies: Available from the American Association of Neuroscience Nurses Web site .

Print copies: Available from the American Association of Neuroscience Nurses, 4700 W. Lake Ave., Glenview, IL 60025.

None provided

None available

This NGC summary was completed by ECRI Institute on September 10, 2009. The information was verified by the guideline developer on September 29, 2009.

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.