TBI-05 · Acute Management of Severe TBI

Acute Management of Severe TBI. Part of the Traumatic Brain Injury series of the Reflex PM&R Board Review podcast. Audio corrections: (1) In the audio: These pharmacological agents typically start 24 to 72 hours after the initial injury, but strictly only once repeat CT imaging definitively confirms the intracranial hemorrhage — Correct: The window is 24 to 48 hours, not 24 to 72. Per ACS Best Practices in the Management of Traumatic Brain Injury (2024), pharmacologic VTE prophylaxis in TBI starts 24 to 48 hours after INJURY: within 24 hours for low-risk nonoperative patients, 24 to 48 hours for moderate and high risk, and 24 to 48 hours after surgery post-craniotomy. The rest of what the episode says stands: mechanical prophylaxis goes on at admission, and the gate on starting the drug is a stable repeat head CT. Note the clock runs from the injury; the stable CT is a conditional gate, never the start of the count. (2) In the audio: That value has to stay strictly below 320 milliosmoles per liter. There is the 320. That 320 is the absolute ceiling. If you push the osmolality higher than 320, you risk inflicting severe acute tubular necrosis and kidney injury. — Correct: There is no validated serum osmolality ceiling for mannitol, and 320 mOsm/L is not a Brain Trauma Foundation number. The fourth edition found the evidence insufficient to make any hyperosmolar recommendation and prints no osmolality threshold; the familiar 320 figure comes from early reports using dosing paradigms no longer in use, and later work found that exceeding 320 mOsm/L did not change the incidence of acute kidney injury. Monitor intravascular volume status, renal function and some measure of serum osmolarity instead, and note that the osmolar gap tracks serum mannitol concentration better than serum osmolarity does. The three numbers to memorize are ICP 22 mmHg, CPP 60 to 70 mmHg, and 7 days of seizure prophylaxis. Everything the passage says next about osmotic diuresis and the contraindication in the hypotensive patient is correct and unaffected. The written chapter is correct. Full correction register: https://www.reflexpmr.com/errata. The full companion chapter and a linked board-style Q-bank set for this topic are at https://www.reflexpmr.com/read/TBI-05.