ACUTE HEAD INJURY - intensive care management
NICE GUIDELINES (2014): assessment and early management
[CG176] January 2014


SIGN GUIDELINES: early management of patients with a head injury (2009)

Aisiku IP, Yamal JM, Doshi P et al (2016) The incidence of ARDS and associated mortality in severe TBI using the Berlin definition. J Trauma Acute Care Surg; 80(2):308-12. doi: 10.1097/TA.0000000000000903
• severe brain injury is associated with an incidence of ARDS ranging from 20% to 25%

Alali AS et al (2014) Tracheostomy timing in traumatic brain injury: A propensity-matched cohort study. J Trauma Inj Inf Crit Care; 76(1):70-78

Andelic N (2013) The complexity of traumatic brain injury. J Rehab Med, 45(8):708-709. doi: 10.2340/16501977-1216

Andrews PJD, Sinclair HL, Rodriguez A et al (2015) Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med; 373:2403-2412. doi: 10.1056/NEJMoa1507581
• therapeutic hypothermia worsens disability and mortality

Arbour R (1998) Aggressive management of intracranial dynamics. Crit.Care Nurse, 18, 3, 30-40
• head elevation can cause hypotension in hypovolaemic patients

Balofsky A, George J, Papadakos P. 2017. Neuropulmonology. Handb Clin Neurol.140:33-48. doi: 10.1016/B978-0-444-63600-3.00003-9

Banham-Hall N, Kothwal K, Pipkin J et al (2013) Prevalence of low bone mineral density in inpatients with traumatic brain injury receiving neurobehavioural rehabilitation: a postoperative, observational study. Physiother; 99(4):328-334

Bartolo M, Bargellesi S, Castioni CA et al (2016) Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study. Europ J Phys Rehab Med; 52(1):90-100

Bhattacharya B, Maung AA (2016) Anesthesia for patients with traumatic brain injuries . Anesthesiol Clinics; 34(4):747-759

Brucia J (1996) The effect of suction catheter insertion and tracheal stimulation in adults with severe brain injury. Heart Lung, 25, 295-303

Bushnik T, Gordon W, Parcel DL et al (2012) Fatigue and sleep disturbance following traumatic brain injury—their nature, causes, and potential treatments. J Head Trauma Rehab, 27(3):224-33
• improved sleep, energy and mood have been achieved by cognitive behaviour therapy, medication and light therapy

Chang WT, Nyquist PA (2013) Strategies for the use of mechanical ventilation in the neurologic intensive care unit. Neurosurg Clin N Am, 24, 3, 407-16. doi: 10.1016/

Chapman BC, Herbert B, Rodil M et al (2016) RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg; 80(1):95-101. doi: 10.1097/TA.0000000000000867
• computed tomography can help predict pulmonary complications

Chapple LS, Chapman MJ, Lange KK et al (2016) Nutrition support practices in critically ill head-injured patients: a global perspective. Crit Care; 20:6 doi:10.1186/s13054

Chudley (1994) The effect of nursing activities on ICP. Br J Nurs, 3, 454-9.
• relatives talking to the patient reduces their ICP, stroking patient’s cheek reduces ICP, positioning is safe with ICP below 15 and CPP above 50 mmHg

Ciurleo R, Bramanti P, Salvatore R et al (2013) Pharmacotherapy for disorders of consciousness: are ‘awakening’ drugs really a possibility? Drugs; 73(17):1849-1862

Crossley S, Reid J, McLatchie R et al (2014) A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. Crit Care; 18:R75. doi. 10.1186/cc13835
• therapeutic hypothermia may benefit some patients

Demirtas-Tatlidede A, Vahabzadeh-Hagh AM, Montserrat Bernabeu M et al (2012) Noninvasive brain stimulation in traumatic brain injury. J Head Trauma Rehab, 27, 4, 274–292
• noninvasive brain stimulation may be used during assessment, or in the acute stage to suppress acute glutamatergic hyperexcitability, or coupled to rehabilitation in the chronic stage to enhance learning new skills

Diringer MN (2016) The evolution of the clinical use of osmotic therapy in the treatment of cerebral edema. Acta Neurochir Suppl; 121:3-6. doi: 10.1007/978-3-319-18497-5_1

Donnelly J, Budohoski K, Smielewski P et al (2016) Regulation of the cerebral circulation: bedside assessment and clinical implications. Crit Care; 20 :129

Eifert B, Maurer-Karattup P, Schorl M et al (2013) Integration of Intensive Care treatment and neurorehabilitation in patients with disorders of consciousness: a program description and case report. Arch Phys Med Rehabil, 94(10):1924–1933
• integrating neurorehabilitation into ICU treatment can benefit even patients in a vegetative state

Ersson U (1990) Observations on intracranial dynamics during respiratory physiotherapy in unconscious neurosurgical patients. Acta Anaesthesiol.Scand, 34, 99-103
• manual hyperinflation and suction both reduce cerebral perfusion pressure; to minimise this, patients should be sedated before physio

Edouard AR (2005) Non-invasive assessment of cerebral perfusion pressure in brain injured patients. Br J Anaesth, 94, 216-21

Eytan D, Pang EW, Doesburg SM et al (2016) Bedside functional brain imaging in critically-ill children using high-density EEG source modeling and multi-modal sensory stimulation. NeuroImage: Clinical; 12:198-211. doi:10.1016/j.nicl.2016.06.021

Fan J-U (2004) Effect of backrest position on intracranial pressure and cerebral perfusion pressure in individuals with brain injury. J Neuroscience Nurs, 36, 5
• systematic review identifying in what circumstances head elevation is and isn’t beneficial

Ferreira LL, Valenti VE, Vanderlei LCM (2013) Chest physiotherapy on intracranial pressure of critically ill patients admitted to the intensive care unit: a systematic review. Revista Brasileira de Terapia Intensiva; 25(4):327-333. doi: 10.5935/0103-507X.20130055
• combined manual techniques and suction transiently increase ICP but not CPP

Fogelberg DF (2012) Association of sleep and co-occurring psychological conditions at 1 year after traumatic brain injury. Arch Phys Med Rehab, 93, 8, 1313-1318

Freeman WD (2015) Management of intracranial pressure. Continuum (Minneap Minn); 21(5 Neurocritical Care):1299-323. doi: 10.1212/CON.0000000000000235

Garradd J, Bullock M (1986) The effect of respiratory therapy on ICP in ventilated neurosurgical patients. Aust J Physiother, 32, 107-11.
• coughing, suction, MHI and vibrations lead to increased ICP

Geng F, Ma Y, Xing T et al (2016) Effects of hyperbaric oxygen therapy on inflammasome signaling after traumatic brain injury. Neuroimmunomodulation; 23(2):122-9. doi: 10.1159/000445689

Gregory T (2012) Cardiovascular complications of brain injury. Contin Educ Anaesth Crit Care Pain, 12, 2, 67-71. doi:10.1093/bjaceaccp/mkr058

Grima N, Ponsford J, Rajaratnam SM et al (2016) Sleep disturbances in traumatic brain injury: a meta-analysis. J Clin Sleep Med; 12(3):419-28. doi: 10.5664/jcsm.5598

Hannawi Y, Abers M, Geocadin R et al (2016) Abnormal movements in critical care patients with brain injury: a diagnostic approach. Crit Care; 20:60

Hart T, Brenner L, Clark AN et al (2011) Major and minor depression after traumatic brain injury original research article. Arch Phys Med Rehabil, 92, 8, 1211-19

Helbok R, Kurtz P, Schmidt MJ et al (2012) Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care, 16:R226. doi:10.1186/cc11880
• doubts about safety of daily interruption of sedation in acutely-head injured patients

Hossain-Ibrahim MK, Tarnaris A, Wasserberg J (2012) Decompressive craniectomy – friend or foe? Trauma, 14, 16-38

Jones B (1995) The effects of patient repositioning on intracranial pressure. Austr J Adv Nurs, 12, 2, 32-9.

Jourdana C, Bayenc E, Pradat-Diehld P et al (2016) A comprehensive picture of 4-year outcome of severe brain injuries. Results from the PariS-TBI study. Ann Physical Rehab Med; 59(2): 100–106. doi:10.1016/

Kenney K, Amyot F, Haber M et al (2016) Cerebral vascular injury in traumatic brain injury. Exp Neurol; 275 Pt 3:353-66. doi: 10.1016/j.expneurol.2015.05.019

Kerr ME (1993) Head-injured adults: recommendations for endotracheal suctioning. J Neuroscience Nursing, 25, 2, 86-91

Khademi S, Frye MA, Jeckel KM et al (2017) Hypoxia mediated pulmonary edema: potential influence of oxidative stress, sympathetic activation and cerebral blood flow. BMC Physiology; 15:4. doi: 10.1186/s12899-015-0018-4

Kim MN, Edlow BL, Durduran T et al (2013) Continuous optical monitoring of cerebral hemodynamics during head-of-bed manipulation in brain-injured adults. Neurocrit Care; 20(3):443-53. doi: 10.1007/s12028-013-9849-7

Kinoshita K (2016) Traumatic brain injury: pathophysiology for neurocritical care. J Int Care; 4:29. doi: 10.1186/s40560-016-0138-3.

Koch SM (1996) Effect of passive range of motion on ICP in neurosurgical patients. J Crit Care, 11, 176-9
• passive range of motion does not affect ICP in stable patients without intracranial hypertension

Lee,S-T (1989) Intracranial pressure changes during positioning of patients with severe head injury. Heart Lung, 18, 411-14.
• head-down tilt increases ICP

Leitgeb J, Mauritz W, Brazinova A et al (2013) Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury. Eur J Trauma Emerg Surg, 39, 3, 285-292

Lelubre C, Bouzat P, Crippa IA et al (2016) Anemia management after acute brain injury. Crit Care; 20:152. doi: 10.1186/s13054-016-1321-6

León-Carrión J, Dominguez-Morales MR, Martin JMB et al (2012) Recovery of cognitive function during comprehensive rehabilitation after severe traumatic brain injury. J Rehab Med, 44, 6, 505-511
• discharge from rehabilitation is not recommended until cognitive improvements are consolidated

Li X, Chen C, Yang X et al (2017) Acupuncture improved neurological recovery after traumatic brain injury by activating BDNF/TrkB pathway. Evid Based Compl Alt Med; Article ID 8460145

Luo X-Y, Hu Y-H, Cao X-Y et al (2016) Lung-protective ventilation in patients with brain injury: a multicenter cross-sectional study and questionnaire survey in China. Chinese Med J; 129(14):1643-1651. doi: 10.4103/0366-6999.185869.

MacKay (1992) Early intervention in severe head injury. Arch Phys Med Rehab, 73, 635-41
• length of coma cut to a third by rehab starting in ICU

Mitchell PH (1978) Relationship of patient-nurse activity to ICP variations. Nurs Research, 27, 4-10.
• venous outflow from the brain is impeded by hip flexion
• talking over the patient increases ICP

Mitchell PH (1981) Moving the patient in bed: effects on ICP. Nurs Research, 30, 212-18.
• raised ICP is caused by noise, pain, restraints, movement of tracheal tube, arousal from sleep or distress

Mrozek S, Constantin JM, Geeraerts T (2015) Brain-lung crosstalk: Implications for neurocritical care patients. World J Crit Care Med; 4(3):163-78. doi: 10.5492/wjccm.v4.i3.163
• brain-lung crosstalk’ via complex pathways leads to both organs exacerbating each other’s troubles
• both manual and ventilator hyperinflation could impede outflow from the brain

Neto ML de C, Moura AV, Cerqueira TCF et al (2013) Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma. Clinics (Sao Paulo); 68(9):1210–1214. doi: 10.6061/clinics/2013(09)06

Ngwenya LB, Burke JF, Manley GT Brain tissue oxygen monitoring and the intersection of brain and lung: a comprehensive review. Respir Care; 61(9):1232-1244

Oddo M, Crippa I, Mehta S et al (2016) Optimizing sedation in patients with acute brain injury. Crit Care; 20:128

Olmos L (2003) Emotion processing in the minimally conscious state. Arch Phys Med Rehab, 84, E7
• patients in a minimally-conscious state show response to familiar voice

Petrov YY, Prough DS (2005) Optoacoustic, noninvasive, real-time, continuous monitoring of cerebral blood oxygenation. Anesthesiol, 102, 69-77;jsessionid=CfLTPPMCuOMZoTJYKxVKLX6LC9oEXG3PCpM4feVzBgwgnPYD7nBn!-1757678366!-949856031!9001!-1

Paraforou T (2012) Cerebral perfusion pressure, microdialysis biochemistry and clinical outcome in patients with traumatic brain injury. BMC Res Notes, 4, 540. doi:10.1186/1756-0500-4-54

Paratz (1993) The effect of respiratory physiotherapy on ICP, BP, CPP and ETCO2 in ventilated neurosurgical patients. Physioth Theory Pract, 9, 3-11.
• effect on ICP of coughing, suction, MHI, vibs, percussion - stop treatment if BP drops or ICP rises

Prinz V, Finger T, Bayerl S et al (2016) High prevalence of pharmacologically induced platelet dysfunction in the acute setting of brain injury. Acta Neurochir (Wien); 158(1):117-23. doi: 10.1007/s00701-015-2645-8
• anticoagulation reduces the risk of thromboembolism, but checking for preexisting medication is required

Reith FCM, Van den Brande R, Synnot A et al (2016) The reliability of the Glasgow Coma Scale: a systematic review. Int Care Med; 42(1): 3-15  

Rudy (1991) Endotracheal suctioning in adults with head injury.
Heart Lung, 20, 667-27.
• rebound increase in ICP may occur 10 minutes after suction

Russo MV, McGavern DB (2016) Inflammatory neuroprotection following traumatic brain injury. Science; 353(6301):783-5. doi: 10.1126/science.aaf6260
• neuroinflammation can persist for years and may contribute to neurodegeneration

Sandsmark DK, Kumar MA, Woodward CS et al (2016) Sleep features on continuous electroencephalography predict rehabilitation outcomes after severe traumatic brain injury. J Head Trauma Rehabil; 31(2):101-7. doi: 10.1097/HTR.0000000000000217

Schroeppel TJ, Sharpe JP, Magnotti LJ et al (2014) Traumatic brain injury and β-blockers: not all drugs are created equal. J Trauma Acute Care Surg; 76(2):504-9. doi: 10.1097/TA.0000000000000104

Seel RT et al (2003) Depression after traumatic brain injury. Arch Phys Med Rehab, 84, 177-84
• depression is common, causes fatigue and distractibility, and requires evaluation and treatment protocols

Siddiqui UT, Tahir MZ, Shamim MS et al (2015) Clinical outcome and cost effectiveness of early tracheostomy in isolated severe head injury patients. Surg Neurol Int; 23;6:65. doi: 10.4103/2152-7806.155757
• if prolonged ventilation is anticipated, early tracheotomy reduces the incidence of VAP

Singer BJ et al (2003) Evaluation of serial casting to correct equinovarus deformity of the ankle after acquired brain injury. Arch Phys Med Rehab, 84, 483-91
• serial casting effective in decreasing deformity and increasing mobility

Sisson (1990) Effects of auditory stimuli on comatose patients with head injury. Heart Lung, 19, 373-8
• unconscious patients can hear everything

Snyder (1983) Relation of nursing activites on ICP. J Adv Nursing, 8,273-9
• ICP increases when staff talk over patient, ICP reduces when families talk to and touch patient

Sommer JB, Norup A, Poulsen I et al (2013) Cognitive activity limitations one year post-trauma in patients admitted to sub-acute rehabilitation after severe traumatic brain injury. J Rehab Med, 45(8):778-784. doi: 10.2340/16501977-1208
• absence of consciousness should not preclude referral to specialized rehabilitation

Spaite DW, Hu C, Bobrow HJ (2017) The effect of combined out-of-hospital hypotension and hypoxia on mortality in major traumatic brain injury. Ann Emerg Med; 69(1):62-72

Stevens RD, Sutter R (2012) Coma emergence and recovery: the new and the old. Crit Care Med, 40, 4, 1352-1353

Stevens JP (2013) Liberating brain-injured patients from mechanical ventilation. Learning from healthcare delivery science. Am J Respir Crit Care Med; 188(8):894-6

Stocchetti N, Zanier ER (2016) Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care; 20:148. doi: 10.1186/s13054-016-1318-1

Stocchetti N, Taccone FS, Citerio G et al (2015) Neuroprotection in acute brain injury: an up-to-date review Crit Care; 19:186. doi: 10.1186/s13054-015-0887-8

Sumidtra P, Sharma D, Hallman M (2014) Preliminary report on cardiac dysfunction after isolated traumatic brain injury. Crit Care Med; 42(1): 142-147. doi: 10.1097/CCM.0b013e318298a890

Sung EJ, Chun MH, Hong JY et al (2016) Effects of a resting foot splint in early brain injury patients. Annals Rehabil Med; 40(1):135-141. doi: 10.5535/arm.2016.40.1.135.

Tehrani FT (2013) A computerized decision support system to predict the variations in the cerebral blood flow of mechanically ventilated infants. Comput Biol Med; 43(10):1402-6

Trofimov A, Kalentiev G, Gribkov A et al (2016) Cerebrovascular time constant in patients with head injury. Acta Neurochir; Suppl.121:295-7. doi: 10.1007/978-3-319-18497-5_51

Turner-Stokes L, Nair A, Sedki I (2011) Multi-disciplinary rehabilitation for brain injury in working-age adults. Cochrane Reviews.

Unden J, Ingebrigtsen T, Romnber B (2013) Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update. BMC Med, 11, 50

Van der Jagt M (2016) Fluid management of the neurological patient: a concise review. Crit Care; 20:126. doi: 10.1186/s13054-016-1309-2

Watson MJ (2001) Do patients with severe traumatic brain injury benefit from physiotherapy? Phys Ther Rev, 6, 233-49
• yes

Wise EK, Hoffman JM, Powell JM et al (2012) Benefits of exercise maintenance after traumatic brain injury. Arch Phys Med Rehab, 93, 8, 1319-1323

Zacchetti L, Magnoni S, Di Corte F et al (2015) Accuracy of intracranial pressure monitoring: systematic review and meta-analysis. Crit Care; 19:420. doi: 10.1186/s13054-015-1137-9

Zanata IL, Santos RS, Hirata GC (2014) Tracheal decannulation protocol in patients affected by traumatic brain injury. Int Arch Otorhinolaryngol; 18(2):108–114. doi: 10.1055/s-0033-1363467

Zhou Q et al (2010) effects of permissive hypercapnia on transient global cerebral ischemia-reperfusion injury in rats. Anesthesiology. 112(2):288-297
• mild to moderate hypercapnia is neuroprotective after transient cerebral injury but severe hypercapnia increases brain injury

CPP = cerebral perfusion pressure
ICP = intracranial pressure
MHI = manual hyperinflation
NICE = National Institute for Health and Care Excellence
SIGN = Scottish Intercollegiate Guidelines Network
VAP = ventilator-associated pneumonia