What is the management approach for traumatic brain injury?

Management Approach for Traumatic Brain Injury

The management of traumatic brain injury (TBI) should follow a tiered approach that prioritizes prevention of secondary brain injury through immediate assessment, neuroimaging, surgical intervention when indicated, and targeted intracranial pressure management. 1

Initial Assessment and Classification

• TBI severity should be evaluated using the Glasgow Coma Scale (GCS), with classification as severe (GCS ≤8), moderate (GCS 9-13), or mild (GCS 14-15) 1
• The motor component of GCS remains most reliable in sedated patients and correlates best with outcome 1
• Key predictors of neurological outcome include age, initial GCS, and pupillary assessment 1
• Early identification of high-risk patients is essential, even in those presenting with mild or moderate TBI 2

Immediate Management Priorities

• Control life-threatening hemorrhage in exsanguinating patients through surgery and/or interventional radiology 1
• Perform urgent neurological evaluation and brain CT scan to determine severity of brain damage 1, 3
• Provide urgent neurosurgical consultation for patients with life-threatening brain lesions 1
• Prevent secondary brain injury by avoiding hypotension, hypoxia, and hypoglycemia 2, 3

Neuroimaging and Surgical Intervention

• Urgent neurosurgical intervention is indicated for depressed skull fractures 1
• Open skull fractures with CSF leak or brain tissue exposure require immediate neurosurgical attention 1
• Clinical decision rules can help identify low-risk patients who may not require neuroimaging 2
• Mass lesions may require surgical evacuation to reduce intracranial pressure 3

Intracranial Pressure (ICP) Monitoring and Management

• ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings 1
• An ICP of 20-40 mmHg is associated with increased mortality risk 1
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 1, 4
• Newer monitoring modalities such as brain tissue oxygen (PbtO₂) monitoring show promise in optimizing cerebral blood flow 3

Tiered Approach to Managing Increased ICP

1. First-tier interventions:

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

2. Second-tier interventions:

   • Hyperosmolar therapy (mannitol or hypertonic saline) 3, 4
   • CSF drainage if ventricular catheter is in place 4
   • In refractory cases, consider barbiturate coma or decompressive craniectomy 3, 4

Management of TBI with Polytrauma

• Balance addressing life-threatening hemorrhage with preventing secondary brain injury 1
• Avoid "permissive hypotension" strategies in TBI patients 1
• Maintain coagulation parameters with PT/aPTT <1.5 times normal control during interventions 1
• Appropriate reversal of anticoagulation should be performed when indicated 3

Additional Management Considerations

• Early seizure prophylaxis should be implemented 3, 4
• Venous thromboembolism (VTE) prophylaxis is important but must be balanced with hemorrhage risk 3
• Recognize and treat paroxysmal sympathetic hyperactivity (PSH) 3, 4
• Optimize nutrition to support recovery 3

Common Pitfalls to Avoid

• Using hypotonic fluids that can worsen cerebral edema 1
• Prolonged hyperventilation which can cause cerebral ischemia 1
• Delaying neurosurgical consultation for patients with severe TBI 1, 2
• Neglecting early palliative care principles in devastating injuries 3

Prehospital Management

• Focus on preventing secondary brain injury through proper airway management and oxygenation 5
• Avoid hypotension through appropriate fluid resuscitation 5, 2
• Consider early transport to trauma centers with neurosurgical capabilities 5
• Implement brain-directed hyperosmolar therapy for signs of impending herniation 5