END ORGAN PERFUSION TARGETED GOAL DIRECTED MANAGEMENT OF A SEVERE TBI PATIENT

Objectives: Traumatic brain injuries (TBI) are a leading cause of death among trauma patients and when they do not prove fatal, are associated with a decrease in the likelihood of meaningful recovery and are associated with multiple morbidities. Treatment of severe TBI patients is focused towards attempting to ameliorate the devastating progressive effects of secondary brain injury that develop due to inflammation, ischemia, and oxidative stress that lead to neuronal damage in the setting of increased intracranial pressure (ICP). First tier treatments in these patients include elevation of the head of bed, adequate analgesia and sedation, hyperventilation, ventriculostomy and ICP monitoring, as well as osmotic therapy with hypertonic saline and/or mannitol. However, patients may develop refractory intracranial hypertension (RICH), defined as intracranial pressure >20mmHg for more than 15 minutes within 1 hour of best management with first tier therapies. In these patients, secondary therapies are often employed, including pentobarbital coma (PBC) and decompressive craniectomy (DC). It is accepted that management of patients with RICH should be focused towards maintaining adequate cerebral perfusion pressure (CPP) as well as the avoidance of hypotension and hypoxia, however, no universal protocol exists regarding how to best accomplish these endpoints.

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