What are the management strategies for traumatic brain injury?

Management of Traumatic Brain Injury

The management of traumatic brain injury (TBI) requires immediate intervention to control life-threatening hemorrhage, followed by urgent neurological evaluation and neurosurgical consultation for patients with life-threatening brain lesions, with continuous monitoring of intracranial pressure (ICP) in patients at risk for intracranial hypertension. 1

Initial Assessment and Resuscitation

Immediate Priorities

• Control of life-threatening hemorrhage: All exsanguinating patients require immediate intervention (surgery and/or interventional radiology) 1
• Airway management: Secure airway with tracheal intubation and mechanical ventilation with end-tidal CO₂ monitoring 1
• Blood pressure management: Maintain systolic BP >100 mmHg or MAP >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
  • For patients without ICP monitoring, maintain systolic BP >110 mmHg 1
  • Avoid hypotension as it significantly worsens neurological outcomes 1

Urgent Neurological Evaluation

• Perform pupillary examination and Glasgow Coma Scale motor score assessment 1
• Obtain immediate brain and cervical CT scan to determine severity of brain damage 1
• Consider CT-angiography of supra-aortic and intracranial arteries in patients with risk factors:
  • Cervical spine fracture
  • Focal neurological deficit not explained by brain imaging
  • Claude Bernard-Horner syndrome
  • Lefort II or III facial fractures
  • Basal skull fractures
  • Soft tissue lesions at the neck 1

Neurosurgical Management

Indications for Neurosurgical Intervention

• Removal of symptomatic extradural hematoma regardless of location
• Removal of significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm)
• Drainage of acute hydrocephalus
• Closure of open displaced skull fracture
• Management of closed displaced skull fracture with brain compression 1

ICP Management

• ICP monitoring is recommended for patients at risk for intracranial hypertension 1
• External ventricular drainage should be performed to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1
• Decompressive craniectomy should be considered to control refractory intracranial pressure after multidisciplinary discussion 1

Prevention and Management of Secondary Brain Injury

Ventilation Management

• Maintain adequate oxygenation (PaO₂ >90 mmHg) 2
• Target normocapnia to prevent cerebral vasoconstriction and risk of brain ischemia 1

Hemodynamic Management

• Avoid hypotension (SBP <110 mmHg) as it significantly increases mortality 1
• Maintain euvolemia and avoid dehydration 2
• Use vasopressors (phenylephrine, norepinephrine) for rapid correction of hypotension 1

ICP and Cerebral Perfusion Management

• Mannitol for reduction of intracranial pressure:
  • Adults: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes
  • Pediatric patients: 1 to 2 g/kg body weight over 30-60 minutes
  • Small or debilitated patients: 500 mg/kg 3
• Contraindications for mannitol:
  • Well-established anuria due to severe renal disease
  • Severe pulmonary congestion or frank pulmonary edema
  • Active intracranial bleeding except during craniotomy
  • Severe dehydration
  • Progressive heart failure or pulmonary congestion after institution of mannitol therapy 3
• Monitor electrolytes every 4-6 hours and maintain normal osmolarity 2

Temperature Management

• Targeted temperature control (TTC) should be considered to modulate cerebral metabolism and ICP 1
• Maintain normothermia as hyperthermia increases risk of complications and is associated with unfavorable outcomes 1

Additional Management Considerations

• Position head and neck in neutral position to prevent increased ICP 2
• Maintain normoglycemia to prevent ischemic acidosis 2
• Consider seizure prophylaxis 4
• Implement venous thromboembolism and stress ulcer prophylaxis 4
• Ensure adequate nutrition and metabolic optimization 4

Monitoring

• Discontinue mannitol if renal, cardiac, or pulmonary status worsens 3
• Monitor for fluid and electrolyte imbalances, particularly hypernatremia and hyponatremia 3
• Monitor cardiovascular status regularly 3

Common Pitfalls and Caveats

• Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol 3
• Be aware that mannitol administration may obscure and intensify inadequate hydration or hypovolemia 3
• Recognize that mannitol may increase cerebral blood flow and risk of postoperative bleeding in neurosurgical patients 3
• Understand that permissive hypotension strategies used for other trauma patients are contraindicated in TBI due to risk of cerebral hypoperfusion 1
• Recognize that secondary injuries were documented in about 90% of patients who died after TBI, highlighting the importance of prevention 2

The management of TBI requires a systematic approach with focus on preventing secondary injury through maintaining adequate cerebral perfusion, controlling ICP, and avoiding systemic insults like hypoxia and hypotension.