What are the guidelines for managing severe traumatic brain injury?

Guidelines for the Management of Severe Traumatic Brain Injury

The management of severe traumatic brain injury requires immediate assessment of severity using the Glasgow Coma Scale (particularly the motor component) and pupillary examination, followed by prompt transfer to a specialized center with neurosurgical facilities. 1

Initial Assessment and Severity Evaluation

Clinical Assessment

• Glasgow Coma Scale (GCS) assessment with focus on motor component (most reliable in sedated patients)
  • Severe TBI: GCS ≤ 8
  • Moderate TBI: GCS 9-13
  • Mild TBI: GCS 14-15 1
• Pupillary size and reactivity examination (critical prognostic indicator) 1
• Repeat neurological examinations frequently to detect secondary deterioration 1

Imaging

• Immediate brain and cervical CT scan for all severe TBI patients (GCS ≤ 8) 1
• CT scan should be performed without delay and include:
  • Nested, inframillimetric sections
  • Double fenestration (central nervous system and bones) 1
• Consider CT-angiography for patients with risk factors for vascular injury 1

Additional Assessment Tools

• Transcranial Doppler (TCD) may be used to assess severity and cerebral perfusion
  • Warning signs: mean blood flow velocity (Vm) < 28 cm/s or high pulsatility index (PI) 1
  • Can be included in FAST assessment for multiple trauma patients 1
• Biomarkers are not recommended for routine clinical use in initial severity assessment 1

Prehospital Management

• Management by pre-hospital medicalized team with rapid transfer to specialized center with neurosurgical facilities 1
• Prioritization in polytrauma patients:
  1. Control of life-threatening hemorrhage first
  2. Urgent neurological evaluation
  3. Neurosurgical consultation for salvageable patients with life-threatening brain lesions 1

Management of Secondary Brain Injury

Hemodynamic Management

• Maintain systolic blood pressure > 100 mmHg or MAP > 80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• Avoid arterial hypotension (systolic BP < 90 mmHg) which significantly increases morbidity and mortality 1
• Maintain cerebral perfusion pressure (CPP) ≥ 60 mmHg when ICP monitoring becomes available 1

Respiratory Management

• Prevent hypoxemia (SaO₂ < 90%) which is associated with poor outcomes 1
• Maintain PaO₂ between 60-100 mmHg during interventions 1
• Maintain PaCO₂ between 35-40 mmHg during interventions 1
• Moderate hyperventilation helps decrease intracranial pressure and partially restores disturbed cerebral autoregulation 2

Intracranial Pressure Management

• ICP monitoring for patients at risk for intracranial hypertension 1
• For cerebral herniation or pending emergency neurosurgery:
  • Use osmotherapy
  • Consider temporary hypocapnia 1
• Stepwise approach to elevated ICP, reserving more aggressive interventions for non-responsive cases 1
• Position head in midline, elevated 30° (if hemodynamically stable) to improve venous return 2

Hematological Management

• Maintain platelet count > 50,000/mm³ for life-threatening hemorrhage interventions
• Higher platelet counts advisable for neurosurgical procedures 1
• Maintain PT/aPTT < 1.5 normal control during interventions 1
• Consider point-of-care tests (TEG, ROTEM) to optimize coagulation 1
• For massive transfusion, begin with RBC/plasma/platelets at 1:1:1 ratio 1

Pharmacological Management

• Analgesia and sedation to prevent ICP increases due to painful stimuli 2
• Avoid inhalational anesthetics including nitrous oxide when increased ICP is suspected 2
• Prefer narcotics, benzodiazepines, and small doses of barbiturates 2
• Osmotically active agents only for emergency situations with clinical deterioration 2

Surgical Management

• Urgent neurosurgical intervention for life-threatening brain lesions 1
• Develop protocols for simultaneous multisystem surgery in patients requiring both neurosurgical and other emergency interventions 1

Special Considerations in Polytrauma

• All exsanguinating patients require immediate intervention for bleeding control before definitive neurological management 1
• After control of life-threatening hemorrhage, urgent neurological evaluation and intervention are required 1
• Red blood cell transfusion for hemoglobin < 7 g/dl during interventions (higher threshold may be used in elderly or patients with limited cardiovascular reserve) 1

Pitfalls and Caveats

• Failure to recognize and treat secondary insults (hypoxia, hypotension) can significantly worsen outcomes
• Delayed transfer to specialized centers increases mortality
• Overaggressive hyperventilation can cause cerebral ischemia
• Neglecting to repeat neurological examinations may miss secondary deterioration
• Failure to implement ICP monitoring in at-risk patients

The management of severe TBI requires a coordinated approach with attention to preventing secondary brain injury while addressing life-threatening systemic injuries. Protocols focusing on ICP monitoring and prevention of secondary insults have been shown to significantly reduce mortality 1.