From the Guidelines
Traumatic brain injury (TBI) management should prioritize a comprehensive approach focusing on preventing secondary injury and optimizing recovery, with initial management involving securing the airway, maintaining adequate oxygenation, and ensuring proper circulation, as recommended by recent guidelines 1.
Key Management Strategies
- Securing the airway and maintaining adequate oxygenation (target SpO2 >94%) are crucial in the initial management of TBI patients.
- Ensuring proper circulation with systolic blood pressure above 100 mmHg is essential to maintain cerebral perfusion.
- For moderate to severe TBI, intracranial pressure (ICP) monitoring is vital, with treatment initiated when ICP exceeds 22 mmHg.
- First-tier interventions include head elevation to 30 degrees, maintaining normothermia, sedation, and osmotherapy with mannitol or hypertonic saline.
- Hyperventilation should be used cautiously and only temporarily, targeting PaCO2 of 30-35 mmHg.
- Seizure prophylaxis with levetiracetam or phenytoin is recommended for the first 7 days in high-risk patients.
- Neurosurgical intervention may be necessary for evacuating hematomas or decompressive craniectomy.
- Rehabilitation should begin early with a multidisciplinary approach including physical, occupational, and speech therapy.
Recent Guidelines and Recommendations
- The World Society of Emergency Surgery (WSES) consensus conference guidelines recommend a comprehensive approach to TBI management, including monitoring and management of severe adult TBI patients with polytrauma in the first 24 hours 1.
- The ESICM/NACCS best practice consensus recommendations emphasize the importance of targeted temperature control following TBI, with a focus on preventing secondary injury and optimizing recovery 1.
- These guidelines and recommendations are based on the latest evidence and expert opinion, and should be prioritized in the management of TBI patients to improve outcomes and reduce morbidity and mortality.
From the Research
Traumatic Brain Injury Management
- Traumatic brain injury is a leading cause of morbidity and mortality worldwide, with approximately 1.6 million cases per year in the US, and 2-6 million patients suffering from disabilities 2.
- The severity of traumatic brain injury can range from mild to severe, and indications for treatment differ based on the injury's severity 2.
- The main goals of early treatment are to prevent secondary brain injury, maintain hemodynamic stability, and monitor and treat intracranial pressure 2, 3.
Medical Treatment
- Medical treatment for severe traumatic brain injury includes maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis 2.
- Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure, but HTS appears to be superior in reducing the combined burden of intracranial hypertension and associated hypoperfusion 4, 5.
- Lower concentrations of HTS may be practical therapeutic agents for patients with TBI given their efficacy in ICP reduction and safer complication profile compared with greater HTS concentrations 5.
Surgical Management
- Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain 2, 3.
- Decompressive craniectomy can be used in refractory cases to reduce intracranial pressure and improve cerebral perfusion pressure 3.
Emerging Treatment Modalities
- Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents 2.
- Brain tissue oxygen (PbtO2) monitoring shows great promise in providing strategies to optimize cerebral blood flow 3.