What is the management of traumatic brain injury?

Management of Traumatic Brain Injury

The management of traumatic brain injury requires immediate transfer to a specialized center with neurosurgical facilities by a pre-hospital medicalized team, followed by urgent brain and cervical CT scanning to guide further interventions. 1

Initial Assessment and Triage

• Severity classification based on Glasgow Coma Scale (GCS):

  • Mild: GCS 13-15
  • Moderate: GCS 9-12
  • Severe: GCS <9

• Immediate priorities:

  • Secure airway with rapid sequence intubation in severe TBI
  • Maintain oxygenation (PaO₂ ≥ 13 kPa/97.5 mmHg)
  • Control ventilation (PaCO₂ between 34-38 mmHg)
  • Maintain systolic blood pressure >110 mmHg 1, 2

• Avoid secondary injury by preventing:

  • Hypotension (maintain MAP >80 mmHg)
  • Hypoxia
  • Hypoglycemia 3

Imaging and Diagnostic Evaluation

• Urgent brain and cervical CT scan without delay in severe TBI 1

  • Sections should be visualized with double fenestration (central nervous system and bones)
  • Inframillimetric sections reconstructed with >1mm thickness

• Consider CT-angiography for patients with risk factors for vascular injury 1

• Consider MRI with specialized sequences (T2* gradient echo, susceptibility-weighted imaging) which are 3-6 times more sensitive than CT for detecting hemorrhagic axonal injuries 2

• Transcranial Doppler can be used as part of initial assessment:

  • Poor prognosis indicators: diastolic flow velocity <20 cm/s and pulsatility index >1.4 1

Neurosurgical Management

• Immediate surgical intervention for:

  • Epidural hematoma
  • Subdural hematoma with significant mass effect
  • Intracerebral hemorrhage with progressive neurological deterioration
  • Depressed skull fractures

• Secondary decompressive craniectomy for refractory intracranial hypertension (after multidisciplinary discussion) 2

Intracranial Pressure (ICP) Management

• ICP monitoring indicated in severe TBI with:

  • Neurological deterioration
  • Inability to perform reliable neurological examinations due to sedation 2

• Measures to control elevated ICP:

  • Head elevation at 20-30° to improve jugular venous outflow 2
  • Ensure euvolemia
  • Sedation with propofol (preferred due to favorable pharmacokinetic profile) 2
  • Consider external ventricular drainage for persistent intracranial hypertension 2
  • Avoid bolus doses of midazolam or opioids which may cause arterial hypotension 2

• Avoid hyperventilation except in cases of impending herniation, where temporary hyperventilation (PaCO₂ not less than 4 kPa) may be used 2

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg in adults prior to measuring cerebral perfusion pressure 1
• Direct arterial pressure monitoring with transducer at the level of the tragus 2
• Ensure euvolemia and maintain MAP >80 mmHg 2

Monitoring

• Continuous end-tidal CO₂ monitoring to maintain PaCO₂ between 34-38 mmHg 2
• ICP monitoring should continue beyond 72 hours in patients with persistent signs of intracranial hypertension 2
• Consider continuous EEG monitoring for detecting nonconvulsive seizure activity 2
• Regular neurological assessments (pupil size and responses) when sedation is lightened 2

Special Considerations

• Avoid premature withdrawal of life-sustaining treatments given the substantial recovery potential even in severely injured patients 2

• Pediatric management requires specialized care with consideration of age-specific physiological parameters

• For mild TBI, clinical decision rules can identify low-risk patients who require no neuroimaging or only brief observation 3

By following this systematic approach to TBI management, focusing on preventing secondary injury and providing appropriate interventions based on severity, patient outcomes can be significantly improved.