Catastrophic Brain Injuries

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 injury guide­lines pro­vide the crit­i­cal care team with com­pre­hen­sive man­age­ment guide­lines to help sup­port the patient through Cushing’s Tri­ad, which is com­mon­ly found in patients with a dev­as­tat­ing brain injury. They can also be used to pre­serve the oppor­tu­ni­ty for dona­tion for the patient and the fam­i­ly if the patient’s injury is non-survivable. 

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 the patient 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.

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Addi­tion­al Resources:

Cat­a­stroph­ic Brain Injury Guide­lines 

Rec­og­niz­ing Signs of Brain Stem Herniation