Catastrophic Brain Injuries

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Treatment of the Patient with a Catastrophic Brain Injury

A patient who sustains catastrophic or devastating brain injuries requires intensive monitoring and treatment, typically in an intensive care setting. Recommended treatment guidelines include:

  • Maintain systolic blood pressure (SBP) greater than 100 mmHg or mean arterial pressure greater than 60 mmHg
  • Treat Diabetes Insipidus to prevent intravascular fluid depletion
  • Maintain oxygenation (PaO2 > 100) and normalize pH balance (7.35 – 7.45) 
  • Ensure core body temperature between 36 C – 38 C
  • Monitor for and treat electrolyte abnormalities
  • Monitor and treat low hemoglobin/hematocrit and disseminated intravascular coagulation (DIC)
Catastrophic brain injuries guidelines are good patient care. They can also be used to preserve the opportunity for donation for the patient and the family if recovery is not possible.


Recognizing Impending Brain Stem Herniation

Several mechanisms can result in brain stem herniation including swelling of brain tissue, fluid collection from intracranial bleeding or cerebrospinal fluid accumulation, and growth of tumors. Brain stem herniation occurs as a result of too much intracranial pressure which forces the brain stem out of its normal space in the skull. Brain stem herniation precedes brain death. Monitor for signs of impending brain stem herniation and notify Iowa Donor Network immediately to preserve donation opportunities.

  • Cushing’s triad
    • Hypertension
    • Bradycardia
    • Respiratory irregularity
  • Loss of brain stem reflexes
    • No pupillary response
    • No corneal response
    • No cough
    • No gag
    • No spontaneous respirations
    • No motor response
    • No response to ice water calorics
    • No doll’s eyes


Many patients become unstable as the brain stem herniates. The opportunity for donation can be preserved with early medical management. It is equally important to provide support to the family members during this difficult time. For more guidance, see Communicating Catastrophic/Traumatic Brain Injuries to a Family.


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