Severe traumatic brain injury
Based on the Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury. A recurring feature of these guidelines is worth noting up front: many long-standing practices carry only Level III recommendations, because the randomised evidence to support something stronger does not exist.
| Parameter | Recommendation | Evidence |
|---|---|---|
| ICP treatment threshold | Treat sustained pressures above 22 mmHg. | Level IIB |
| Cerebral perfusion pressure | Target 60–70 mmHg; the individual optimum varies. | Level IIB |
| Blood pressure | Avoid hypotension — a single episode is associated with markedly worse outcome. | Level III |
| Hyperventilation | Not recommended prophylactically; a temporising measure only, and avoided in the first 24 hours. | Level IIB |
| Corticosteroids | Not recommended — associated with increased mortality in the CRASH trial. | Level I |
| Seizure prophylaxis | Phenytoin reduces early post-traumatic seizures; no benefit shown for late seizures. | Level IIA |
| Nutrition | Feed to full caloric replacement by day five to seven. | Level IIA |
Note the asymmetry: the strongest recommendation in the list is a negative one. Steroids seemed physiologically sensible for decades until a large trial showed they caused harm — a useful reminder about mechanism-based reasoning in the absence of outcome data.