My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives for families of critically ill patients in intensive care, so that you can make informed decisions, have peace of mind, control, power and influence making sure your loved one always gets the best care and treatment, even if you’re not a doctor or a nurse in intensive care.

So, today I have another quick tip for families in intensive care and I’m addressing a very important reader question from Peter about his dad who’s in ICU with a traumatic brain injury (TBI), and brain swelling, in an induced coma for 7 days, and the ICU team has now started to wake him up by tapering the sedation drugs.

Peter’s question is so important, and I know it resonates with thousands of families all around the world going through the same incredible incredibly stressful experience right now. So let me break this down for you clearly and in plain English.

Peter writes:

Hi Patrik,

My dad’s been in ICU in an induced coma for 7 days, with traumatic brain injury (TBI), and brain swelling. They have started the process to release him from the induced coma by tapering the drugs.

I have two questions.

1. Will it take hours or days for him to wake up?
2. Once semi-awake, how long and how do they stay on life support or breathing ventilation?

-Peter

So, let’s start with what is a traumatic brain injury (TBI), and why is the induced coma used.

A traumatic brain injury or TBI occurs when an external force causes brain dysfunction, most commonly from a fall, motor vehicle accident, or assault. In severe TBI, the brain can swell significantly, which is called cerebral edema. When the brain is swelling inside the skull, there is no room to expand. This causes a dangerous rise in intracranial pressure (ICP). Elevated ICP can reduce blood flow to the brain, causing secondary brain injury on top of the original injury. This is exactly why the ICU team induces a coma. They induced coma using drugs like propofol, midazolam, also known as Versed, or barbiturates such as, Phenobarbital or thiopental.

It does the following:

1. It reduces the brain’s metabolic demand. The brain needs less oxygen when sedated.
2. It lowers ICP intracranial pressure by reducing brain activity.
3. It prevents dangerous spikes in pressure from coughing, pain, or agitation.
4. It protects the brain while it heals.

In severe cases, the ICU team also uses a procedure called an external ventricular drain, also known as EVD, which is a catheter inserted into the fluid-filled spaces of the brain – the ventricles, to drain excess cerebrospinal fluid (CSF) and directly monitors and controls ICP.

Now, let’s also look now at understanding ICP and CPP, the two numbers that matter most. In TBI management, the ICUT monitors two critical numbers around the clock.

Number 1. ICP (intracranial pressure). Normal ICP is between 5 to 15 mmHg. In TBI, the target is to keep ICP below 20 to 22 mmHg. If ICP rises above this, the brain is under dangerous pressure, and blood flow is compromised.

Number 2. CPP (cerebral perfusion pressure). CPP is the pressure that drives blood into the brain. It is calculated as CPP = MAP (mean arterial pressure) – ICP (intracranial pressure). The target CPP is generally 60 to 70 mmHg.

This means the ICU team is not just managing ICP, they are simultaneously managing blood pressure to ensure adequate brain perfusion. If CPP drops too low, the brain doesn’t get enough blood flow. If it is too high, it can worsen swelling. This is a very delicate balancing act. The ICU team titrates medications, fluids, sedation, head positioning, and ventilator settings, all to keep these two numbers in a safe range.

Let’s now look at treatments used to manage brain swelling and ICP in ICU. Here’s what the ICU team typically uses to manage brain swelling and high ICP in TBI patients.

Number 1. Sedation and paralysis. Drugs like propofol, midazolam, also known as Versed, fentanyl, morphine, or barbiturates such as phenobarbital or thiopentone are used to keep the brain in low activity state. In severe cases, neuromuscular blocking agents, also known as muscle relaxants, are added to prevent any movement that could spike ICPs.

Number 2. Osmotherapy, mannitol, and hypertonic saline. These are medications given intravenously to draw fluids out of the brain cells and reduce swelling. Mannitol is a traditional osmotic agent. Hypertonic saline, concentrated salt solution, is increasingly preferred, work by creating an osmotic gradient, pulling water out of swollen brain tissue into the bloodstream where it can be filtered by the kidneys. This requires obviously to monitor sodium levels quite closely because if sodium goes out of normal levels, it can cause seizures and other electrolyte management issues.

Number 3. Ventilator management controls CO2 (carbon dioxide) levels. The ventilator plays a critical role in TBI. CO2 is a powerful regulator of brain blood vessel size. When CO2 rises, blood vessels dilate, increasing blood volume in the brain and raising ICP. The ICU team carefully controls ventilator settings to keep CO2 in a normal range, 35 to 45 mmHg, or in acute crisis, briefly lowers CO2 through hyperventilation to temporarily constrict brain blood vessels and reduce ICP.

Number 4. Head positioning. The head of the bed is typically elevated to 30 degrees. The neck is kept neutral, not rotated or flexed, to allow good venous drainage from the brain. This helps lower ICP.

Number 5. External ventricular drain, also known as extra ventricular drainage. I mentioned it briefly earlier, an EVD is a small catheter placed by neurosurgeons through the skull into the ventricles of the brain. It serves two purposes. It monitors ICP continuously in real time, and it can drain lesser amounts of CSF (cerebrospinal fluid) to immediately reduce the pressure in the brain or ICP when it spikes. This is one of the most direct and effective ways to manage dangerously elevated ICPs. The drain is carefully managed with specific drainage parameters set by the neurosurgical team.

Number 6. Surgical intervention – decompressive craniectomy. In cases where ICPs cannot be controlled with all the above measures, neurosurgeons may remove a portion of the skull, also known as decompressive craniectomy, to physically give the swollen brain room to expand without being crushed against the skull. The bone flap is typically restored and reimplanted months later once the brain has recovered.

Number 7. Temperature management. Fever dramatically increases the brain’s metabolic demand and worsens ICP. The ICU team keeps the patient’s temperature tightly controlled, often using cooling blankets or intravascular cooling catheters to maintain normothermia (normal body temperature), or in some cases therapeutic hypothermia (low body temperature).

So, let’s now also look in more details at Peter’s questions.

Will it take hours or days for his dad to wake up?

This is one of the most common and most anxious questions families ask, and the answer is it depends, and it can be both hours and days and sometimes even longer. And here’s why, when the ICU team tapers the drugs, they are gradually reducing the sedation medications. As the drugs wear off, the brain slowly regains its ability to respond, but unlike waking from normal sleep or general anesthesia for surgery, waking from a medically induced coma after a TBI is far more complex.

Factors that determine how quickly someone wakes up after TPI induced coma include:

1. Severity and location of the original brain injury
2. Degree of brain swelling, and how much it has resolved.
3. How long the sedation drugs were used and which drugs were used. Some accumulate in body fat.
4. Whether ICP has stabilized and is no longer elevated
5. Liver and kidney function, which affects how quickly drugs are cleared.
6. Overall medical stability. Is there infection, fever, low blood pressure?

In practice, some patients begin to show signs of wakefulness, eye opening, grimacing, moving limbs within hours of sedation being reduced. Others can take days to show meaningful responses, especially after prolonged deep sedation and potentially muscle paralysis. And critically, waking up after TBI is often not a clear sudden event. It is a gradual fluctuating process. Your dad may open his eyes but not track. He may follow simple commands on some occasions but not on others. He may be agitated and confused, which is very common – it is called post-traumatic agitation or ICU delirium or ICU psychosis. He may have periods of appearing more awake than less awake.

The ICU team typically uses a neurological assessment tool called the GCS (Glasgow Coma Scale) to track awakening. Scores range from 3, which is the deepest coma, to 15, which is fully awake. They will also watch for pupillary responses, motor responses, and ability to follow commands.

In short, waking up after an induced coma, especially after TBI is more like waking up, it’s like switching on a light with a dimmer instead of switching on a light with a switch. It goes slow and gradual.

The most important thing I want Peter and every family watching this or reading this to understand is do not interpret early confusion, agitation, or inconsistent responsiveness as a sign that your loved one will not recover. These are often normal and expected phases of TBI recovery.

Now, let’s come to Peter’s next question.

Once semi-awake, how long do they stay on life support and ventilation?

This is where things become very individual and very important for families to understand clearly. Just because someone starts waking up from the induced coma does not mean they can immediately breathe on their own or come off the ventilator. The ability to breathe safely and independently requires adequate consciousness and brain function, enough brain activity to drive breathing, airway protection, the ability to swallow, cough, and protect the airway from secretions, adequate respiratory muscle strength, sufficient gas exchange. The lungs must work well enough to oxygenate the blood. In TBI patients, the brain injury itself can impair all these things, especially airway protection and the drive to breathe. So even as consciousness returns, the ventilator may need to stay in place for days to weeks, longer.

Let’s now look at the weaning process.

The ICU team will start to reduce ventilation support progressively. They will conduct daily spontaneous breathing trials where the patient breathes more on their own with minimal ventilator support to assess readiness for extubation, which is the removal of the breathing tube. If your dad passes these trials, meaning he can breathe adequately on his own and protect his airway, the endotracheal tube/breathing tube through the mouth, can be removed. This is called extubation.

What if he can’t be weaned off the ventilator?

If weaning is difficult or not possible within days to weeks, the ICU team may recommend a tracheostomy – a surgical opening in the throat that allows long term ventilation in a more comfortable and safer way than the tube through the mouth. A tracheostomy makes long-term ventilation more manageable and makes the weaning process easier in many cases. Patients with a tracheostomy can sometimes begin to speak with a speaking valve, eat with supervision, and engage in rehabilitation even while still requiring ventilation support.

Peter, and every family reading or watching this, I cannot stress this enough, why getting access to all medical records is absolutely critical. You need to access; all your dad’s medical records immediately. The medical records will tell you exactly what is happening with his brain, what his ICP readings have been, what medications are being used, and at what doses, what the neurosurgical team’s assessment have found, what the results of CT scans and MRI scans show, and what the ICU team’s plan is for weaning off the ventilator.

Families often feel in the dark, they are told general updates but don’t have the full clinical picture. The full clinical picture is what allows you to ask the right questions, understand the realistic prognosis, and advocate effectively for your loved one. You have the legal right to access your family member’s medical records. Don’t wait. Request them now.

This is exactly why I created intensivecarehotline.com. When your loved one is in ICU, you need an experienced critical care specialist nurse in your corner, someone who can review the medical records with my team, help you understand what is happening clinically, and speak with you and potentially with the ICU team on your behalf.

And here is what we do for you. Review all medical records including CT scans, CT scan reports, nursing notes, medication charts, ventilation, parameters, ICP/CPP readings, neurosurgical assessments, laboratory results, arterial blood gas results, fluid balance charts. Leave no stone unturned.

We explain to you in plain English what the numbers and clinical findings mean for your loved one’s prognosis, help you formulate the right questions to ask the ICU team, advocate alongside you, including being available to speak with the ICU team directly during family meetings or ward rounds, help you understand your options and your rights.

You can book a consulting call with me or one of my team members at intensivecarehotline.com by clicking on the schedule appointment button or by calling me on one of the numbers on the top of our website at intensivecarehotline.com, or you can send us an email to [email protected]. We work with families all over the world.

So, let’s now look at long-term home ventilation and intensive care at home what if your dad can’t be weaned.

For some TBI patients, Peter, particularly those with severe brain injuries, ventilator weaning may be a very slow or sometimes even impossible process that might require long-term ventilation indefinitely. And I want families to know that long-term ventilation with tracheostomy does not have to mean staying in ICU forever. Intensivecareathome.com can take your dad home. We are the first fully accredited intensive care at home nursing provider in Australia, and we have been caring for ventilated patients in their own homes since 2012 in Australia. Intensive Care at Home can support patients who need long-term invasive ventilation with a tracheostomy at home, non-invasive ventilation such as BiPAP/CPAP at home, also for tracheostomy patients without ventilation, because many patients after TBI unfortunately need a tracheostomy.

Palliative care in the comfort of your own home, complex nursing care following ICU discharge, NDIS funded, specialist support coordination level 2 and level 3 for eligible patients, TAC and WorkSafe case management, keeping a ventilator dependent patient at home with the right team is safe, clinically sound, and in most cases by far better for quality of life than remaining in ICU long-term. It is also more cost effective for the healthcare system. As a matter of fact, it, it’s only 50% compared to an ICU bed, so therefore funding bodies will have an interest in funding intensive care at home.

If your loved one’s ICU team has raised the possibility that your family member may need long-term ventilation or a tracheostomy, please reach out to us at intensivecareathome.com to understand what your options are and what are the possibilities for intensive care at home.

So, to summarize, what you need to know about TBI, induced coma, and ICU waking. TBI causes brain swelling, also known as cerebral edema and elevated ICP, which the induced coma helps control. The ICU team manages ICP and CPP using sedation, osmotherapy, mannitol, hypertonic saline, ventilation management to control CO2, EVD drainage, positioning and temperature control.

Waking from an induced coma after TBI can take hours to days. It is gradual and often inconsistent. Staying on the ventilator after waking is common. Breathing safely requires specific abilities that TPI can impair. A tracheostomy may be recommended for long-term ventilation and weaning. Getting access to all medical records is critical. You need the full clinical picture. Intensive Care Hotline can review your medical records, consult with you, and advocate with the ICU team with you and on your behalf. If long-term ventilation is needed, intensivecareathome.com can support care safely outside ICU with 24-hour intensive care nurses at home.

And I hope this gives you, Peter, and your family some clarity during what I know is an incredibly stressful and difficult time. Your dad has a whole team working to protect his brain. And now you have us to help make sure you understand everything that is happening and that you can advocate for him effectively.

Reach out to us at intensivecarehotline.com today. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] or book an appointment with me on the scheduled appointment button at intensivecarehotline.com.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

The biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care.

That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to families directly, I also talk to doctors and nurses directly, asking all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

I also represent you in family meetings with intensive care teams.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.