Empiric Hypertonic Saline Administration in Patients With Traumatic Brain Injuries

Introduction: Empiric initiation of hypertonic saline (HTS) can provide significant benefit in reducing neurological damage in traumatic brain injury (TBI); however, HTS has been associated with significant adverse events. Although a CT scan should be performed to confirm elevated intracranial pressure (ICP) and neurologic injury, HTS can be administered empirically if there is evidence for suspected elevated ICP from clinical history. This medication use evaluation aims to characterize the usage and timing of HTS for TBI in the emergency department (ED) and its relevant adverse effects.


Methods: This a single-center, retrospective chart review of all adult patients administered HTS in the West Virginia University J.W. Ruby Memorial ED with concern for a TBI. The primary objective was to evaluate the number of patients who received HTS therapy in the emergency department for suspected or confirmed TBI. Secondary objectives included the description of HTS dosing, identification of adverse effects that may be related to HTS administration (hypernatremia, hyperchloremia, and renal dysfunction), and analysis of HTS administrations before CT for patients without TBI.


Results: A total of 106 patients who received at least one bolus of HTS in the ED were included. The population included 79 patients (74.5%) that had a confirmed TBI and 27 patients (25.5%) that did not have a TBI. HTS was administered prior to CT scan in 51 patients (48.1%); 16 patients (31.3%) did not have a confirmed TBI after the CT scan was completed. HTS was administered in 11 patients (10.4%) who had a CT prior to HTS and did not have a confirmed TBI. The common presentations of the patients without a TBI were found down or post fall (13/27; 48.1%), followed by motor vehicle crashes (9/27; 33.3%). The HTS median dose was 250 milliliters (IQR 250-250), median administration time of 30 minutes (IQR 30-30), and cumulative volume of 250 milliliters (250-500). The most significant adverse event was hyperchloremia with 40 patients (37.7%); hyperchloremic acidosis occurred in 6 patients.


Conclusions: Empiric HTS was initiated in a considerable number of the population without a confirmed TBI. In addition, an elevated number of no TBI patients were identified that had HTS administration after imaging which may require HTS institutional optimization.