Temperature and Traumatic Brain Injury

OVERVIEW

  • induced hypothermia has been used for years to reduced cerebral metabolic rate.
  • manipulation of temperature has been shown to effect certain types of brain injury (therapeutic hypothermia in out-of-hospital cardiac arrest).
  • the data in traumatic brain injury differs.

DEFINTIONS

  • normothermia: T 36-38 C
  • hypothermia: T < 36 C – hyperthermia: T > 38 C
  • therapeutic hypothermia: T 32-33 C (usually for 48 hours post injury)

THERAPEUTIC HYPOTHERMIA

NEJM, 2001

  • MRCT
  • normothermia vs moderate hypothermia (T33 C for 48 hours)
  • improved ICP but no reduction in mortality
  • patients > 45 years do worse with induced hypothermia
  • if a patient arrives hypothermic -> do not warm to 37 (poorer outcome)
  • if a patient arrives hypothermic -> they will have a significantly worse TBI
  • increased risk of ventilatory acquired pneumonia

BTF Guidelines

  • moderate quality trials
  • cooling to 32-33 C
  • no reduction in mortality
  • patients treated with hypothermia were more likely to have favourable neurological outcomes (Glasgow Outcome Score of 4 or 5)
  • need to cool for 48 hours

FEVER

  • aggressive avoidance of fever early in TBI beneficial (lowers ICP)
  • aim for normothermia (?what is normothermia)
  • ?how long is it beneficial to control fever

AN APPROACH

First 48 hours

  • if cold on arrival, don’t actively warm
  • if normothermic, maintain
  • if hyperthermic, treat cause and cool to normothermia
  • don’t use therapeutic hypothermia

After 48 hours

  • cool if having trouble controlling ICP (after having attempted other treatments and informing neurosurgeons)
  • otherwise allow to be febrile

CCC Neurocritical Care Series

  • Brain Trauma Foundation Guidelines – Guidelines for the Management of Severe TBI
  • Clifton GL, Miller ER, Choi SC, Levin HS, McCauley S, Smith KR Jr, Muizelaar JP, Wagner FC Jr, Marion DW, Luerssen TG, Chesnut RM, Schwartz M. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001 Feb 22;344(8):556-63. PubMed PMID: 11207351. [Free Fulltext]

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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