What are the guidelines for managing traumatic brain injury?

Management Guidelines for Traumatic Brain Injury

The management of traumatic brain injury (TBI) requires a systematic, stepwise approach with interventions escalated based on patient response, reserving more aggressive treatments for refractory cases to optimize patient outcomes and reduce mortality and morbidity. 1

Initial Severity Assessment and Classification

• TBI severity should be evaluated using the Glasgow Coma Scale (GCS), with severe TBI defined as GCS ≤8, moderate TBI as GCS 9-13, and mild TBI as GCS 14-15 2
• Intracranial hypertension should be suspected and treated when major criteria (compressed cisterns, midline shift >5mm, non-evacuated mass lesion) or two minor criteria (GCS motor score ≤4, pupillary asymmetry, abnormal pupillary reactivity, Marshall diffuse injury II) are present 2
• CT scanning is the mainstay of risk stratification in emergency departments and dictates the need for further intervention 3

Monitoring Recommendations

• ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings, as more than 50% of these patients will develop intracranial hypertension 1
• An ICP of 20-40 mmHg is associated with a 3.95 times higher risk of mortality and poor neurological outcome; above 40 mmHg, mortality risk increases 6.9-fold 1
• Despite widespread use, evidence demonstrating that ICP-guided therapy improves outcomes remains limited, highlighting the importance of clinical judgment alongside monitoring 4

First-Tier Interventions for ICP Management

• Position the head elevated at 20-30° to assist venous drainage and minimize edema formation 1
• Provide sedation and analgesia following protocols similar to non-brain injured patients, with modifications for ICP control 1
• Maintain adequate cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 1
• Control ventilation to maintain PaCO2 between 35-40 mmHg during routine management 1
• Avoid hypotension, as decreased cerebral perfusion pressure below 60 mmHg can worsen brain edema and secondary injury 1

Second-Tier Interventions

• Apply temporary hyperventilation (PaCO2 30-35 mmHg) only for acute ICP crises or signs of herniation 1
• Osmotherapy with hypertonic saline or mannitol can be used for refractory intracranial hypertension 2, 1
• Avoid hypo-osmolar fluids that may worsen cerebral edema 1

Third-Tier Interventions

• Decompressive craniectomy may reduce mortality (26.9% vs 48.9% in medical management) but potentially at the expense of increased severe disability 1
• The RESCUE-ICP study showed decompressive craniectomy reduced mortality compared to barbiturate coma but did not improve favorable outcomes at 6 months 1
• Bifrontal craniectomy was associated with worse outcomes in the DECRA study and should be used cautiously 1

Critical Parameters to Maintain

• Oxygenation: Maintain PaO2 between 60-100 mmHg 1
• Ventilation: Maintain PaCO2 between 35-40 mmHg (except during temporary hyperventilation for herniation) 1
• Coagulation: Maintain platelet count >50,000/mm³ for life-threatening hemorrhage and higher for neurosurgical interventions 1
• Hemostasis: Keep PT/aPTT <1.5 times normal control during interventions 1

Management of TBI with Polytrauma

• For patients with both TBI and extracranial injuries causing bleeding, there is a challenging balance between addressing life-threatening hemorrhage and preventing secondary brain injury 2
• Avoid "permissive hypotension" strategies in TBI patients as arterial hypotension exacerbates cerebral secondary damage 2
• For patients requiring both neurosurgical intervention and treatment for life-threatening hemorrhage elsewhere, protocols for simultaneous multisystem surgery should be established 1

Pitfalls to Avoid

• Daily interruption of sedation may be harmful in TBI patients with signs of high ICP 1
• Corticosteroids have not shown benefit in TBI and are not recommended for ICP control 1
• Avoid hypotension at all costs, as it significantly worsens outcomes 1, 5
• For patients with severe and moderate TBI, management should occur in neuroscience centers, regardless of the need for neurosurgical intervention 3
• For patients with acute subdural or extradural hematomas, time from clinical deterioration to operation should be minimized, as delays affect outcomes 3

Special Considerations

• In cases of cerebral herniation, osmotherapy and/or temporary hypocapnia are recommended while awaiting definitive management 1
• Point-of-care coagulation tests (TEG, ROTEM) should be utilized when available to guide coagulation management 1
• Patients with post-concussion syndrome benefit from supportive management in multi-disciplinary neurotrauma clinics 3
• Specialist neurorehabilitation after TBI is important for improving long-term outcomes 3