What is the management of traumatic brain injury?

Management of Traumatic Brain Injury

The management of traumatic brain injury (TBI) requires immediate transfer to a specialized center with neurosurgical facilities by a pre-hospital medicalized team to optimize patient outcomes and reduce mortality. 1

Initial Assessment and Classification

• TBI severity is primarily assessed using the Glasgow Coma Scale (GCS), with severe TBI defined as GCS < 9, requiring immediate intensive management 1
• Brain and cervical computed tomography (CT) scan should be performed without delay in severe TBI patients to identify primary brain lesions and guide neurosurgical interventions 1
• Transcranial Doppler (TCD) measurements on arrival can be useful to assess cerebral perfusion, with concerning findings including diastolic blood flow velocity < 20 cm/s and pulsatility index > 1.4 1
• Biomarkers (S100b, NSE, UCH-L1, GFAP) are not recommended for routine clinical assessment of TBI severity 1

Pre-hospital Management

• Patients with severe TBI should be managed by a specialized pre-hospital medical team and transferred as quickly as possible to centers with neurosurgical capabilities 1
• Systolic blood pressure should be maintained > 110 mmHg prior to measuring cerebral perfusion pressure to ensure adequate cerebral perfusion 1
• Secure airway management through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring is essential to prevent secondary brain injury 2
• Target an EtCO2 between 30-35 mmHg prior to obtaining arterial blood gases to guide ventilation adjustments 1

Imaging Strategy

• Immediate brain and cervical CT scan with inframillimetric sections and double fenestration (central nervous system and bones) is the reference standard for TBI assessment 1
• Consider early CT-angiography of supra-aortic and intracranial arteries in patients with risk factors for vascular injury 1
• Serial imaging may be necessary to monitor progression of injuries and guide ongoing management 1

Management of Increased Intracranial Pressure (ICP)

First-Line Interventions

• Implement standard ICP management including restriction of free water, avoidance of excess glucose, minimization of hypoxemia and hypercarbia, treatment of hyperthermia, and elevation of head of bed to 20-30° 2
• Control ventilation to maintain appropriate PaCO2 levels through mechanical ventilation 2
• External ventricular drainage should be performed for persistent intracranial hypertension despite sedation and correction of secondary brain insults 2

Second-Line Interventions

• Osmotic diuretics such as mannitol (0.25-0.5 g/kg IV over 20 minutes every 6 hours, maximum 2 g/kg) can be used to reduce ICP 2
• Hypertonic saline is effective for patients with clinical transtentorial herniation 2
• For intubated patients, mild hyperventilation targeting PaCO2 of 30-35 mmHg can temporarily reduce ICP, though benefits are short-lived 2
• Consider decompressive craniectomy for refractory intracranial hypertension following multidisciplinary discussion 2

Important Considerations

• Corticosteroids are NOT recommended for TBI management as they have failed to demonstrate beneficial effects on mortality or neurological outcomes 2
• Meta-analyses show no difference in mortality risk between dexamethasone treatment and control groups (RR 1.14,95% CI 0.91-1.42), with some studies suggesting potential harm 2
• In patients with concomitant traumatic brain injury and chest trauma, maintaining PaCO₂ between 35-40 mmHg after stabilization is crucial to prevent cerebral vasoconstriction 3
• Avoid hyperoxia after stabilization while ensuring adequate oxygenation during the acute phase 3
• Consider other causes of shock in trauma patients, including hemorrhagic shock, which may require additional interventions 3

Management in Resource-Limited Settings

• Focus on preventing secondary injury by avoiding hypotension, hypoxia, and hypoglycemia, which can be implemented at all facility levels 4
• Use clinical decision rules to identify low-risk patients who may not require neuroimaging or only brief observation 4
• Systematic approach to severe TBI should be prioritized even when advanced resources are limited 4