Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

ACC 2024 Congress

Catch up on all the top stories and latest evidence in cardiology research with our ACC 2024 Congress hub page.
ADVANCED SEARCH
Log in
Top
Neurocritical Care
Published in: Neurocritical Care 1/2015

01-08-2015 | Review Article

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

A Position Statement for Healthcare Professionals from the Neurocritical Care Society

Authors: Michael J. Souter, Patricia A. Blissitt, Sandralee Blosser, Jordan Bonomo, David Greer, Draga Jichici, Dea Mahanes, Evie G. Marcolini, Charles Miller, Kiranpal Sangha, Susan Yeager

Published in: Neurocritical Care | Issue 1/2015

Login to get access

Abstract

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.
Appendix
Available only for authorised users
Literature
1.
Dixon TD, Malinoski DJ. Devastating brain injuries: assessment and management part I: overview of brain death. West J Emerg Med. 2009;10(1):11–7.PubMedCentralPubMed
2.
Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–2.PubMedCrossRef
3.
Andrews JC, Schunemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–35.PubMedCrossRef
4.
Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–25.PubMedCrossRef
5.
Kotwica Z, Jakubowski JK. Head-injured adult patients with GCS of 3 on admission–who have a chance to survive? Acta Neurochir (Wien). 1995;133(1–2):56–9.CrossRef
6.
Towfighi A, Tai W, Markovic D, Ovbiagele B. Sex-specific temporal trends in in-hospital mortality after stroke among middle-age individuals in the United States. Stroke. 2011;42(10):2740–5.PubMedCrossRef
7.
Ovbiagele B. Nationwide trends in in-hospital mortality among patients with stroke. Stroke. 2010;41(8):1748–54.PubMedCrossRef
8.
Arabi YM, Haddad S, Tamim HM, Al-Dawood A, Al-Qahtani S, Ferayan A, et al. Mortality reduction after implementing a clinical practice guidelines-based management protocol for severe traumatic brain injury. J Crit Care. 2010;25(2):190–5.PubMedCrossRef
9.
Sturgeon JD, Folsom AR. Trends in hospitalization rate, hospital case fatality, and mortality rate of stroke by subtype in Minneapolis-St. Paul, 1980-2002. Neuroepidemiology. 2007;28(1):39–45.PubMedCrossRef
10.
Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database. J Neurosurg. 2008;108(6):1163–9.PubMedCrossRef
11.
Parry-Jones AR, Abid KA, Di Napoli M, Smith CJ, Vail A, Patel HC, et al. Accuracy and clinical usefulness of intracerebral hemorrhage grading scores: a direct comparison in a UK population. Stroke. 2013;44(7):1840–5.PubMedCrossRef
12.
Lu J, Marmarou A, Choi S, Maas A, Murray G, Steyerberg EW. Mortality from traumatic brain injury. Acta Neurochir Suppl. 2005;95:281–5.PubMedCrossRef
13.
Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–7.PubMedCrossRef
14.
Hemphill JC III, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004;35(5):1130–4.PubMedCrossRef
15.
Wang W, Lu J, Wang C, Wang Y, Li H, Zhao X. Prognostic value of ICH score and ICH-GS score in Chinese intracerebral hemorrhage patients: analysis from the China National Stroke Registry (CNSR). PLoS ONE. 2013;8(10):e77421.PubMedCentralPubMedCrossRef
16.
Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6(1):1–9.PubMedCrossRef
17.
Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe A, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol. 2011;10(7):618–25.PubMedCrossRef
18.
Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg. 1988;68(6):985–6.
19.
Gotoh O, Tamura A, Yasui N, Suzuki A, Hadeishi H, Sano K. Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery 1996;39(1):19–24; discussion-5.
20.
Hirai S, Ono J, Yamaura A (1996) Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery 1996;39(3):441–446; discussion 6–7.
21.
Lagares A, Gomez PA, Lobato RD, Alen JF, Alday R, Campollo J. Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochir (Wien). 2001;143(7):665–72.CrossRef
22.
Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care. 2005;2(2):110–8.PubMedCrossRef
23.
Aulmann C, Steudl WI, Feldmann U. Validation of the prognostic accuracy of neurosurgical admission scales after rupture of cerebral aneurysms. Zentralbl Neurochir. 1998;59(3):171–80.PubMed
24.
25.
Massagli TL, Michaud LJ, Rivara FP. Association between injury indices and outcome after severe traumatic brain injury in children. Arch Phys Med Rehabil. 1996;77(2):125–32.PubMedCrossRef
26.
Gatson JW, Warren V, Abdelfattah K, Wolf S, Hynan LS, Moore C, et al. Detection of beta-amyloid oligomers as a predictor of neurological outcome after brain injury. J Neurosurg. 2013;118(6):1336–42.PubMedCrossRef
27.
Chabok SY, Moghadam AD, Saneei Z, Amlashi FG, Leili EK, Amiri ZM. Neuron-specific enolase and S100BB as outcome predictors in severe diffuse axonal injury. J Trauma Acute Care Surg. 2012;72(6):1654–7.PubMedCrossRef
28.
Settervall CH, de Sousa RM. Furbringer e Silva SC. In-hospital mortality and the Glasgow Coma Scale in the first 72 hours after traumatic brain injury. Rev Lat Am Enfermagem. 2011;19(6):1337–43.PubMed
29.
Eriksson EA, Barletta JF, Figueroa BE, Bonnell BW, Sloffer CA, Vanderkolk WE, et al. The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury. J Trauma Acute Care Surg. 2012;72(5):1345–9.PubMed
30.
Kahraman S, Dutton RP, Hu P, Xiao Y, Aarabi B, Stein DM, et al. Automated measurement of “pressure times time dose” of intracranial hypertension best predicts outcome after severe traumatic brain injury. J Trauma. 2010;69(1):110–8.PubMedCrossRef
31.
van Santbrink H, Schouten JW, Steyerberg EW, Avezaat CJ, Maas AI. Serial transcranial Doppler measurements in traumatic brain injury with special focus on the early posttraumatic period. Acta Neurochir (Wien). 2002;144(11):1141–9.CrossRef
32.
Wolach B, Sazbon L, Gavrieli R, Broda A, Schlesinger M. Early immunological defects in comatose patients after acute brain injury. J Neurosurg. 2001;94(5):706–11.PubMedCrossRef
33.
Togha M, Bakhtavar K. Factors associated with in-hospital mortality following intracerebral hemorrhage: a three-year study in Tehran. Iran BMC Neurol. 2004;4:9.PubMedCrossRef
34.
Becker KJ, Baxter AB, Cohen WA, Bybee HM, Tirschwell DL, Newell DW, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72.PubMedCrossRef
35.
O’Callahan JG, Fink C, Pitts LH, Luce JM. Withholding and withdrawing of life support from patients with severe head injury. Crit Care Med. 1995;23(9):1567–75.PubMedCrossRef
36.
Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60(2):274–8.PubMedCrossRef
37.
Brody A, Kashuk JL, Moore EE, Beauchamp K, Barnett C, Biffl WL, et al. (2010) Fatal gunshot wounds to the head: a critical appraisal of organ donation rates. Am J Surg. 2010;200(6):728–733; discussion 33.
38.
Combes P, Fauvage B, Colonna M, Passagia JG, Chirossel JP, Jacquot C. Severe head injuries: an outcome prediction and survival analysis. Intensive Care Med. 1996;22(12):1391–5.PubMedCrossRef
39.
Murano T, Mohr AM, Lavery RF, Lynch C, Homnick AT, Livingston DH. Civilian craniocerebral gunshot wounds: an update in predicting outcomes. Am Surg. 2005;71(12):1009–14.PubMed
40.
Bershad EM, Farhadi S, Suri MF, Feen ES, Hernandez OH, Selman WR, et al. Coagulopathy and inhospital deaths in patients with acute subdural hematoma. J Neurosurg. 2008;109(4):664–9.PubMedCrossRef
41.
Park SK, Chun HJ, Kim DW, Im TH, Hong HJ, Yi HJ. Acute physiology and chronic health evaluation II and simplified acute physiology score II in predicting hospital mortality of neurosurgical intensive care unit patients. J Korean Med Sci. 2009;24(3):420–6.PubMedCentralPubMedCrossRef
42.
Labib N, Nouh T, Winocour S, Deckelbaum D, Banici L, Fata P, et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma. 2011;71(6):1908–14.PubMedCrossRef
43.
Cho DY, Wang YC. Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome. Intensive Care Med. 1997;23(1):77–84.PubMedCrossRef
44.
Alvarez M, Nava JM, Rue M, Quintana S. Mortality prediction in head trauma patients: performance of Glasgow Coma Score and general severity systems. Crit Care Med. 1998;26(1):142–8.PubMedCrossRef
45.
Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care. 2006;10(Suppl 2):S2.PubMedCentralPubMedCrossRef
46.
Dalgic A, Ergungor FM, Becan T, Elhan A, Okay O, Yuksel BC. The revised Acute Physiology and Chronic Health Evaluation System (APACHE II) is more effective than the Glasgow Coma Scale for prediction of mortality in head-injured patients with systemic trauma. Ulus Travma Acil Cerrahi Derg. 2009;15(5):453–8.PubMed
47.
Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J Trauma. 2008;65(4):785–8.PubMedCrossRef
48.
Zafonte RD, Wood DL, Harrison-Felix CL, Millis SR, Valena NV. Severe penetrating head injury: a study of outcomes. Arch Phys Med Rehabil. 2001;82(3):306–10.PubMedCrossRef
49.
Arboix A, Marti-Vilalta JL. Predictive clinical factors of very early in-hospital mortality in subarachnoid hemorrhage. Clin Neurol Neurosurg. 1999;101(2):100–5.PubMedCrossRef
50.
Zhang G, Zhang JH, Qin X. Fever increased in-hospital mortality after subarachnoid hemorrhage. Acta Neurochir Suppl. 2011;110(Pt 1):239–43.
51.
Arboix A, Massons J, Garcia-Eroles L, Oliveres M, Targa C. Diabetes is an independent risk factor for in-hospital mortality from acute spontaneous intracerebral hemorrhage. Diabetes Care. 2000;23(10):1527–32.PubMedCrossRef
52.
Fanshawe M, Venkatesh B, Boots RJ. Outcome of stroke patients admitted to intensive care: experience from an Australian teaching hospital. Anaesth Intensive Care. 2002;30(5):628–32.PubMed
53.
Cucchiara BL, Kasner SE, Wolk DA, Lyden PD, Knappertz VA, Ashwood T, et al. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit Care Med. 2004;32(1):241–5.PubMedCrossRef
54.
Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, et al. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With the Guidelines-Stroke Program. Circulation. 2010;122(15):1496–504.PubMedCrossRef
55.
Savadi-Oskouei D, Sadeghi-Bazargani H, Hashemilar M, DeAngelis T. Symptomatologic versus neuroimaging predictors of in-hospital survival after intracerebral haemorrhage. Pak J Biol Sci. 2010;13(9):443–7.PubMedCrossRef
56.
Rordorf G, Koroshetz W, Efird JT, Cramer SC. Predictors of mortality in stroke patients admitted to an intensive care unit. Crit Care Med. 2000;28(5):1301–5.PubMedCrossRef
57.
Bond AE, Draeger CR, Mandleco B, Donnelly M. Needs of family members of patients with severe traumatic brain injury. Implications for evidence-based practice. Crit Care Nurse. 2003;23(4):63–72.PubMed
58.
Frid I, Bergbom I, Haljamae H. No going back: narratives by close relatives of the braindead patient. Intensive Crit Care Nurs. 2001;17(5):263–78.PubMedCrossRef
59.
Keenan A, Joseph L. The needs of family members of severe traumatic brain injured patients during critical and acute care: a qualitative study. Can J Neurosci Nurs. 2010;32(3):25–35.PubMed
60.
Lam P, Beaulieu M. Experiences of families in the neurological ICU: a “bedside phenomenon”. J Neurosci Nurs. 2004;36(3):142–146, 51–55.
61.
Payne S, Burton C, Addington-Hall J, Jones A. End-of-life issues in acute stroke care: a qualitative study of the experiences and preferences of patients and families. Palliat Med. 2010;24(2):146–53.PubMedCrossRef
62.
Mathis M. Personal needs of family members of critically ill patients with and without acute brain injury. J Neurosurg Nurs. 1984;16(1):36–44.PubMedCrossRef
63.
Prachar TL, Mahanes D, Arceneaux A, Moss BL, Jones S, Conaway M, et al. Recognizing the needs of family members of neuroscience patients in an intensive care setting. J Neurosci Nurs. 2010;42(5):274–9.PubMedCrossRef
64.
Tin MK, French P, Leung KK. The needs of the family of critically ill neurosurgical patients: a comparison of nurses’ and family members’ perceptions. J Neurosci Nurs. 1999;31(6):348–56.PubMedCrossRef
65.
Forrester DA, Murphy PA, Price DM, Monaghan JF. Critical care family needs: nurse-family member confederate pairs. Heart Lung. 1990;19(6):655–61.PubMed
66.
Price DM, Forrester DA, Murphy PA, Monaghan JF. Critical care family needs in an urban teaching medical center. Heart Lung. 1991;20(2):183–8.PubMed
67.
Engli M, Kirsivali-Farmer K. Needs of family members of critically ill patients with and without acute brain injury. J Neurosci Nurs. 1993;25(2):78–85.PubMedCrossRef
68.
Duff D. Family concerns and responses following a severe traumatic brain injury: a grounded theory study. Axone. 2002;24(2):14–22.PubMed
69.
Merritt KL, Evans RL. Family satisfaction with medical care after traumatic brain injury. Psychol Rep. 1990;67(1):129–30.PubMedCrossRef
70.
Lefebvre H, Pelchat D, Swaine B, Gelinas I, Levert MJ. The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Inj. 2005;19(8):585–97.PubMedCrossRef
71.
Long B, Clark L, Cook P. Surrogate decision making for patients with severe traumatic brain injury. J Trauma Nurs. 2011;18(4):204–12.PubMedCrossRef
72.
Wellwood I, Dennis M, Warlow C. Patients’ and carers’ satisfaction with acute stroke management. Age Ageing. 1995;24(6):519–24.PubMedCrossRef
73.
Lefebvre H, Levert MJ. Breaking the news of traumatic brain injury and incapacities. Brain Inj. 2006;20(7):711–8.PubMedCrossRef
74.
Kesselring A, Kainz M, Kiss A. Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU. Am J Transpl. 2007;7(1):211–7.CrossRef
75.
Schats R, Brilstra EH, Rinkel GJ, Algra A, Van Gijn J. Informed consent in trials for neurological emergencies: the example of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 2003;74(7):988–91.PubMedCentralPubMedCrossRef
76.
Fox S, Jeffrey J. The role of the nurse with families of patients in ICU: the nurses’ perspective. Can J Cardiovasc Nurs = Journal canadien en soins infirmiers cardio-vasculaires. 1997;8(1):17–23.
77.
Mirr MP. Factors affecting decisions made by family members of patients with severe head injury. Heart Lung. 1991;20(3):228–35.PubMed
78.
White DB, Cua SM, Walk R, Pollice L, Weissfeld L, Hong S, et al. Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness. Am J Crit Care. 2012;21(6):396–409.PubMedCentralPubMedCrossRef
79.
Bernstein LP. Family-centered care of the critically III neurologic patient. Crit Care Nurs Clinics North Am. 1990;2(1):41–50.
80.
Mirr MP. Decisions made by family members of patients with severe head injury. AACN Clin Issues Crit Care Nurs. 1991;2(2):242–51.PubMed
81.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24(Suppl 1):S7–13.PubMed
82.
Toms SA. Outcome predictors in the early withdrawal of life support: issues of justice and allocation for the severely brain injured. J Clin Ethics. 1993;4(3):206–11.PubMed
83.
Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111(4):683–7.PubMedCentralPubMedCrossRef
84.
Council on Ethical and Judicial Affairs AMA. Decisions near the end of life. JAMA. 1992;267(16):2229–33.CrossRef
85.
Cruzan v. Director, Missouri Dept. of Health: Hearing before the United States Reports, United States Reports, 497 Sess. (1990, 1990).
86.
Gillett GR, Honeybul S, Ho KM, Lind CR. Neurotrauma and the RUB: where tragedy meets ethics and science. J Med Ethics. 2010;36(12):727–30.PubMedCrossRef
87.
Sander SL, Miller BK. Public knowledge and attitudes regarding organ and tissue donation: an analysis of the northwest Ohio community. Patient Educ Couns. 2005;58(2):154–63.PubMedCrossRef
88.
89.
Baumann A, Claudot F, Audibert G, Mertes PM, Puybasset L. The ethical and legal aspects of palliative sedation in severely brain-injured patients: a French perspective. Philos Ethics Hum Med. 2011;6:4.CrossRef
90.
Dyer C. Appeal Court supports doctors’ decision not to treat. BMJ. 1992;304(6841):1527–8.PubMed
Metadata
Title
Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management
A Position Statement for Healthcare Professionals from the Neurocritical Care Society
Authors
Michael J. Souter
Patricia A. Blissitt
Sandralee Blosser
Jordan Bonomo
David Greer
Draga Jichici
Dea Mahanes
Evie G. Marcolini
Charles Miller
Kiranpal Sangha
Susan Yeager
Publication date
01-08-2015
Publisher
Springer US
Published in
Neurocritical Care / Issue 1/2015
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-015-0137-6

Other articles of this Issue 1/2015

Neurocritical Care 1/2015 Go to the issue

Original Article

Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study

Original Article

Endotracheal Intubation in Patients Treated for Prehospital Status Epilepticus

Practical Pearl

The Hemodynamic Response of Spreading Depolarization Observed by Near Infrared Spectroscopy After Aneurysmal Subarachnoid Hemorrhage

Original Article

Temporal Changes in Left Ventricular Systolic Function and Use of Echocardiography in Adult Heart Donors

Original Article

Changes in Cerebral Partial Oxygen Pressure and Cerebrovascular Reactivity During Intracranial Pressure Plateau Waves

Editorial

Observations on Ethical Issues in the Neuro-ICU