Second-Tier Therapy in the Treatment of Traumatic Brain Injury: What Is and What Should Never Be

ABSTRACT

Intracranial hypertension is a common complication of severe traumatic brain injury (TBI). Current treatment for intracranial hypertension involves insertion of an intracranial pressure (ICP) monitor followed by maintenance of cerebral perfusion pressure and reduction of ICP, if elevated. Current therapy to reduce elevated ICP includes ventricular drainage, sedation, osmotic diuretics, paralysis, and mild hyperventilation. In 10 to 15% of patients, this type of first-tier therapy fails to reduce ICP. Failure of first-tier therapy carries a mortality of 84 to 100%. For this group of patients, second-tier therapies are available and include barbiturates, focused hyperventilation, hypothermia, and decompressive craniectomy. Although not experimental, these types of therapy do not have significant evidenced-based studies to support strong guidelines. This article reviews each of these therapies along with their advantages and disadvantages.

KEYWORDS

Barbiturates - craniectomy - hyperventilation - hypothermia - traumatic brain injury

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