What are the tiered guidelines for managing traumatic brain injury (TBI)?

Tiered Guidelines for Managing Traumatic Brain Injury (TBI)

The management of traumatic brain injury requires a structured, tiered approach focusing on preventing secondary injury through specialized care in neurosurgical facilities, with specific protocols for assessment, monitoring, and intervention based on injury severity. 1

Initial Assessment and Severity Classification

Clinical Evaluation

• Assess TBI severity using:
  • Glasgow Coma Scale (GCS), particularly the motor response component
  • Pupillary size and reactivity
  • Age (key prognostic factor) 1

Severity Classification

• Severe TBI: GCS ≤ 8
• Moderate TBI: GCS 9-13
• Mild TBI: GCS 14-15

Neurological Monitoring Schedule

• Moderate TBI (higher risk of deterioration):
  • Every 15-30 minutes for first 2 hours
  • Then hourly for next 4-12 hours 1
• Any decrease of ≥2 points in GCS requires immediate repeat CT scan

Tier 1: Pre-Hospital Management

Transport and Triage

• Strong recommendation: Manage severe TBI patients with a pre-hospital medicalized team and transfer directly to specialized centers with neurosurgical facilities 1
• Avoid secondary insults (hypoxia, hypotension) during transport

Airway and Breathing

• Secure airway in patients with GCS ≤ 8
• Target EtCO2 between 30-35 mmHg before arterial gas sampling
• Maintain SpO2 > 95% 1

Circulation

• Maintain systolic blood pressure > 110 mmHg in adults 1
• Avoid hypotonic solutions
• Use isotonic crystalloids for volume resuscitation

Tier 2: Emergency Department Management

Immediate Imaging

• Perform brain and cervical CT scan without delay in severe TBI patients 1
• Consider CT-angiography in patients with risk factors for vascular injury 1

Systemic Assessment

• Investigate and correct systemic factors that can cause secondary cerebral insults:
  • Hypotension (SBP < 90 mmHg)
  • Hypoxemia (PaO2 < 60 mmHg)
  • Hypercapnia or severe hypocapnia
  • Anemia (Hb < 7 g/dL)
  • Hypo/hyperglycemia
  • Hypo/hyperthermia 1

Hemodynamic Targets

• Maintain euvolemia
• Avoid hypotension at all costs 2
• Target cerebral perfusion pressure (CPP) as a surrogate for cerebral blood flow

Tier 3: Neurosurgical Interventions

Surgical Indications

• Evacuation of mass lesions (epidural/subdural hematomas)
• Decompressive craniectomy in selected cases
• External ventricular drainage for hydrocephalus

Cerebral Monitoring

• Consider intracranial pressure (ICP) monitoring in severe TBI patients (GCS ≤ 8) with abnormal CT scan
• Consider brain tissue oxygen monitoring in selected cases 1
• Use transcranial Doppler to assess cerebral blood flow (diastolic velocity < 20 cm/s and pulsatility index > 1.4 indicate poor perfusion) 1

Tier 4: ICU Management of Intracranial Hypertension

First-Line Measures

• Head elevation (30°)
• Sedation and analgesia
• Normothermia
• Osmotherapy (mannitol or hypertonic saline)
• CSF drainage if ventricular catheter present

Second-Line Measures

• Moderate hyperventilation (PaCO2 30-35 mmHg)
• Barbiturate coma
• Moderate hypothermia
• Decompressive craniectomy 1, 3

Monitoring Targets

• ICP < 20-22 mmHg
• CPP > 60-70 mmHg
• Brain tissue oxygen > 15 mmHg (if monitored)

Tier 5: Management of Systemic Complications

Prophylaxis

• Venous thromboembolism prophylaxis
• Stress ulcer prophylaxis
• Seizure prophylaxis in high-risk patients 2

Metabolic Management

• Maintain normoglycemia
• Provide adequate nutrition (preferably enteral)
• Monitor and correct electrolyte imbalances 1

Resource-Tiered Approach

Basic Resources (Tier 1)

• Clinical assessment using GCS
• Prevention of secondary injury (airway, breathing, circulation)
• Basic neurological monitoring
• Transfer protocols to higher-level facilities 4

Intermediate Resources (Tier 2)

• CT scanning capability
• Basic neurosurgical interventions
• ICP monitoring
• ICU care with basic ventilation 4

Advanced Resources (Tier 3)

• Specialized neuro-ICU
• Advanced monitoring (brain tissue oxygen, cerebral blood flow)
• Complex neurosurgical interventions
• Rehabilitation services 4

Pediatric Considerations

• Lower CPP targets based on age
• Different osmotherapy dosing
• Higher risk of diffuse cerebral swelling
• Different prognostic factors 1

Common Pitfalls to Avoid

• Delayed transfer to neurosurgical centers - associated with worse outcomes
• Hypotension - even a single episode significantly increases mortality
• Hyperventilation without ICP monitoring - can cause cerebral ischemia
• Overhydration with hypotonic fluids - worsens cerebral edema
• Failure to recognize deterioration - requires frequent neurological assessments
• Reliance on biomarkers for clinical decision-making - not yet recommended for routine use 1

The tiered approach to TBI management emphasizes prevention of secondary injury through specialized care, appropriate monitoring, and targeted interventions based on injury severity and available resources.