Push Dose Pearls: Managing Severe TBI

Caring for patients with severe traumatic brain injury (TBI)—especially pediatric patients—is high-stakes and high-stress. In severe TBI, primary brain injury occurs at the moment of impact; our primary goal in the emergency department is preventing secondary brain injury caused by hypoxia, hypoperfusion, elevated intracranial pressure (ICP), seizures, hyperthermia, and dysglycemia.

In this episode, ED Clinical Pharmacist Haley Burhans returns to walk us through key medications for the acute management of severe TBI. We’ll cover airway management, rapid sequence intubation (RSI) drug choices, hyperosmolar therapy, seizure prophylaxis, TXA, and post-resuscitation care.

1. Airway & Rapid Sequence Intubation (RSI)

Optimizing oxygenation and ventilation is critical, as hypoxemia directly contributes to secondary brain injury. Selecting hemodynamically neutral agents is essential to maintain cerebral perfusion pressure (CPP).

Induction Agents

• Etomidate (0.3 mg/kg, max 40 mg): Hemodynamically neutral, making it a reliable choice for TBI patients with unstable or uncertain blood pressures.
• Ketamine (1–2 mg/kg): Excellent option for borderline low or hypotensive patients. Historical concerns regarding ketamine-induced ICP spikes have been largely disproven; bolus doses <5 mg/kg do not cause sustained ICP elevations and offer valuable analgesia.

Paralytics

• Succinylcholine (1.5 mg/kg TBW, max 200 mg): Preferred if an immediate post-intubation neurological exam is required by neurosurgery, given its short duration (~10–15 min).
• Rocuronium (1.0–1.2 mg/kg): Higher dosing ensures rapid onset. Preferred when securing the airway smoothly and keeping the patient still for immediate CT scanning is the priority. Note: Paralyzes the patient for 45–60 minutes, so obtain a baseline neuro exam first or have a plan for reversal if an early exam is needed.

Pre-Medications (Lidocaine vs. Fentanyl)

• Lidocaine (1.5 mg/kg): Theoretically blunts airway-reflex-induced ICP spikes during intubation, but takes 2–5 minutes to reach peak effect and introduces cardiac risks in undifferentiated trauma patients. Generally omitted when rapid airway placement is required.
• Fentanyl (1–2 mcg/kg): Preferred pre-medication for hypertensive or tachycardic patients to blunt sympathetic surges and prevent ICP spikes during laryngoscopy.

2. Post-Intubation Sedation & Hemodynamic Support

• Hypotensive / Unstable: Push-dose Ketamine (1–2 mg/kg) provides deep sedation while preserving blood pressure.
• Hypertensive / Stable: Propofol infusion (Adults: ~40 mcg/kg/min; Pediatrics: ~60 mcg/kg/min due to faster metabolism) helps suppress ICP and optimize CPP.
• Pressors: If vasopressors are required to maintain target SBP (>100–110 mmHg depending on age), titrate carefully to clear hemody