What is the management approach for traumatic brain injury?

Management of Traumatic Brain Injury

The management of traumatic brain injury requires a systematic approach focused on initial severity assessment, prevention of secondary injury, appropriate monitoring, and timely interventions to optimize patient outcomes and reduce mortality and disability.

Initial Assessment and Classification

• Severity of traumatic brain injury (TBI) should be evaluated using the Glasgow Coma Scale (GCS), with specific attention to motor response, pupillary size, and reactivity 1
• TBI is classified as:
  • Severe: GCS ≤8
  • Moderate: GCS 9-13
  • Mild: GCS 14-15 2
• The motor component of GCS remains most robust in sedated patients and correlates best with outcome 1
• Age, initial GCS, and pupillary assessment are key predictors of neurological outcome at 6 months 1

Immediate Management Priorities

• Control life-threatening hemorrhage in exsanguinating patients through surgery and/or interventional radiology 1
• Secure airway and ensure adequate oxygenation to prevent hypoxia (maintain PaO2 between 60-100 mmHg) 2, 3
• Maintain hemodynamic stability and avoid hypotension, as decreased cerebral perfusion pressure below 60 mmHg worsens brain edema and secondary injury 2
• Perform urgent neurological evaluation (pupils + GCS motor score) and brain CT scan to determine severity of brain damage 1
• Provide urgent neurosurgical consultation and intervention for patients with life-threatening brain lesions 1, 3

Neuroimaging and Surgical Intervention

• Brain CT scan should be performed on all patients with suspected moderate to severe TBI 4
• Patients with acute subdural or extradural hematomas requiring surgery should have minimal time from clinical deterioration to operation 3
• Indications for urgent neurosurgical intervention include:
  • Epidural or subdural hematomas with mass effect
  • Depressed skull fractures
  • Open skull fractures with CSF leak or brain tissue exposure 1, 3

Intracranial Pressure (ICP) Monitoring and Management

• ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings, as more than 50% will develop intracranial hypertension 2
• Intracranial hypertension should be suspected 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) are present 2
• An ICP of 20-40 mmHg is associated with 3.95 times higher risk of mortality; above 40 mmHg, mortality risk increases 6.9-fold 2
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 2

Tiered Approach to Managing Increased ICP

First-Tier Interventions

• Control ventilation to maintain PaCO2 between 35-40 mmHg 2
• Elevate head of bed to 30 degrees to improve venous drainage 2
• Ensure adequate sedation and analgesia 1
• Maintain normothermia and treat seizures 2

Second-Tier Interventions

• Osmotherapy with hypertonic saline or mannitol for refractory intracranial hypertension 2
• Avoid hypo-osmolar fluids that may worsen cerebral edema 2
• Consider temporary hyperventilation only for acute herniation 2

Third-Tier Interventions

• Decompressive craniectomy may reduce mortality (26.9% vs 48.9% with medical management) but potentially at the expense of increased severe disability 2
• The RESCUE-ICP study showed decompressive craniectomy reduced mortality compared to barbiturate coma but did not improve favorable outcomes at 6 months 2

Management of TBI with Polytrauma

• For patients with both TBI and extracranial injuries causing bleeding, balance addressing life-threatening hemorrhage with preventing secondary brain injury 2
• Avoid "permissive hypotension" strategies in TBI patients as arterial hypotension exacerbates cerebral secondary damage 2
• Maintain coagulation parameters: platelet count >50,000/mm³ for life-threatening hemorrhage and higher for neurosurgical interventions 2
• Keep PT/aPTT <1.5 times normal control during interventions 2
• Point-of-care coagulation tests (TEG, ROTEM) should be utilized when available 2

Post-Acute Management

• Patients with severe and moderate TBI should be managed in neuroscience centers, regardless of the need for neurosurgical intervention 3
• Patients with mild TBI and negative brain CT may be discharged from the emergency department if they have no other injuries requiring admission 4
• Patients taking warfarin who present with mild TBI should have their INR determined, and those with supratherapeutic values should be admitted for observation 4
• Deficits in cognition and memory usually resolve within 1 month but may persist longer in 20-40% of cases 4

Complications and Long-term Considerations

• TBI can lead to visual difficulties, cognitive deficits, headache, sleep disturbances, and post-traumatic epilepsy 5
• Neuropsychological evaluation can assist in assessing the patient's clinical condition and developing interventional strategies 6
• Specialist neurorehabilitation after TBI is important for improving outcomes 3
• Patients with post-concussion syndrome benefit from supportive management in multi-disciplinary neurotrauma clinics 3

Common Pitfalls to Avoid

• Delaying neurosurgical intervention for patients with expanding hematomas 3
• Using hypotonic fluids that can worsen cerebral edema 2
• Prolonged hyperventilation which can cause cerebral ischemia 2
• Failure to identify and treat coagulopathy in patients on anticoagulants 4
• Neglecting to transfer moderate and severe TBI patients to neuroscience centers 3