What is the immediate treatment for Traumatic Brain Injury (TBI)?

Immediate Management of Traumatic Brain Injury (TBI)

The immediate treatment for traumatic brain injury (TBI) requires rapid assessment of severity using the Glasgow Coma Scale (GCS), securing airway/breathing/circulation, and prompt transfer to a specialized neurosurgical center while maintaining systolic blood pressure above 110 mmHg to ensure adequate cerebral perfusion. 1

Initial Assessment and Triage

• Severity Assessment:

  • Use Glasgow Coma Scale (GCS), focusing on motor response component
  • Evaluate pupillary size and reactivity
  • Document all three components of GCS (Eye-Verbal-Motor) 1

• Immediate Red Flags Requiring Emergency Intervention:

  • Loss of consciousness
  • Repeated vomiting
  • Worsening headache
  • Altered mental status
  • Seizures
  • Focal neurological deficits 2

Immediate Interventions (First Minutes)

1. Airway Management:

   • Secure airway in unconscious patients
   • Consider rapid sequence intubation for GCS ≤8
   • Maintain oxygen saturation >90% 1

2. Breathing:

   • Target EtCO2 between 30-35 mmHg prior to arterial blood gas sampling
   • Avoid hypoxia at all costs 1

3. Circulation:

   • Maintain systolic blood pressure >110 mmHg in adults 1
   • Secure IV access with two large-bore catheters
   • Use isotonic crystalloids for volume resuscitation 1

4. Disability:

   • Perform rapid neurological assessment
   • Document GCS and pupillary responses
   • Assess for signs of increased intracranial pressure 1

Immediate Diagnostic Workup

1. Imaging:

   • Perform brain and cervical CT scan without delay 1
   • Consider CT-angiography for patients with risk factors for vascular injury 1
   • Avoid routine spinal immobilization without specific indications 2

2. Laboratory Studies:

   • Complete blood count
   • Coagulation profile
   • Blood type and cross-match
   • Arterial blood gases
   • Serum electrolytes 1

Management of Increased Intracranial Pressure (ICP)

For signs of increased ICP or cerebral herniation:

1. Pharmacological Management:

   • Mannitol: 0.25-2 g/kg IV as 15-25% solution over 30-60 minutes 3
     • Monitor for reduction in CSF pressure within 15 minutes of administration
     • Use with caution in patients with renal impairment (elimination half-life prolonged to ~36 hours) 3
   • Hypertonic Saline: Alternative to mannitol in hypovolemic patients 1

2. Positioning:

   • Elevate head of bed 30° (if no contraindications)
   • Maintain head in neutral position
   • Avoid tight cervical collars that may impede venous return 2

Transfer to Definitive Care

1. Specialized Center Transfer:

   • Transfer to a center with neurosurgical facilities as soon as possible 1
   • Management by a pre-hospital medicalized team improves outcomes 1
   • Communicate GCS, pupillary findings, and interventions to receiving facility 1

2. During Transport:

   • Continue monitoring vital signs
   • Maintain adequate cerebral perfusion pressure
   • Prevent secondary insults (hypoxia, hypotension, hypoglycemia) 4

Prevention of Secondary Brain Injury

1. Avoid Hypotension:

   • Maintain systolic BP >110 mmHg 1
   • Ensure euvolemia using isotonic fluids 5

2. Avoid Hypoxia:

   • Maintain SpO2 >90%
   • Ensure adequate ventilation 1

3. Metabolic Management:

   • Prevent hypoglycemia
   • Maintain normothermia
   • Correct electrolyte abnormalities 6

Pitfalls to Avoid

• Do not delay transfer to definitive care for extensive diagnostic workup
• Do not allow hypotension or hypoxia at any point during resuscitation
• Do not administer hypotonic fluids which can worsen cerebral edema
• Do not routinely hyperventilate patients unless signs of herniation are present
• Do not place 25% Mannitol in polyvinylchloride (PVC) bags (white flocculent precipitate may form) 3
• Do not allow patients with even mild TBI to return to physical activity until properly evaluated 2

The management of TBI requires a coordinated approach focusing on preventing secondary injury through maintaining adequate cerebral perfusion while rapidly identifying patients requiring neurosurgical intervention. Early transfer to specialized centers with neurosurgical capabilities significantly improves outcomes in severe TBI patients.