What is the management approach for traumatic brain injury?

Management Approach for Traumatic Brain Injury

The management of traumatic brain injury (TBI) requires a tiered approach focused on preventing secondary brain injury through immediate assessment using the Glasgow Coma Scale, urgent neuroimaging, maintaining cerebral perfusion pressure ≥60 mmHg, and providing appropriate neurosurgical intervention for life-threatening lesions. 1

Initial Assessment and Classification

• TBI severity should be evaluated using the Glasgow Coma Scale (GCS), with particular attention to motor response, pupillary size, and reactivity 1
• Classification is based on GCS scores: severe (GCS ≤8), moderate (GCS 9-13), or mild (GCS 14-15) 1
• Age, initial GCS, and pupillary assessment are key predictors of neurological outcome at 6 months 1
• The motor component of GCS remains most reliable in sedated patients and correlates best with outcome 1

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, 2
• Provide urgent neurosurgical consultation for patients with life-threatening brain lesions 1
• Avoid secondary brain injury by preventing hypotension, hypoxia, and hypoglycemia 2

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 management 1
• Clinical decision rules can help identify low-risk patients who may not require neuroimaging 2
• Mass lesions identified on imaging may require surgical evacuation 3

Intracranial Pressure (ICP) Monitoring and Management

• ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings 1
• Intracranial hypertension should be suspected when major criteria or two minor criteria are present 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

Tiered Approach to Managing Increased ICP

1. First-tier interventions:

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

2. Second-tier interventions for refractory intracranial hypertension:

   • Hyperosmolar therapy with mannitol or hypertonic saline 3, 4
   • CSF drainage if ventricular catheter is in place 3, 4
   • In severe 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 and reverse anticoagulation as indicated 1, 3
• Keep PT/aPTT <1.5 times normal control during interventions 1

Advanced Monitoring and Supportive Care

• Brain tissue oxygen (PbtO2) monitoring shows promise in optimizing cerebral blood flow 3
• Early seizure prophylaxis is recommended, particularly in high-risk patients 3, 4
• Implement venous thromboembolism (VTE) prophylaxis once bleeding risk is controlled 3
• Optimize nutrition to support recovery 3
• Recognize and treat paroxysmal sympathetic hyperactivity (PSH) when present 3, 4

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
• Failing to identify and manage increased ICP in a timely manner 1, 4
• Neglecting to address coexisting injuries in polytrauma patients 1, 3