What are the class 1 recommendations for moderate and severe Traumatic Brain Injury (TBI) management?

Class I Recommendations for Moderate and Severe TBI Management

The strongest Class I recommendation for moderate and severe traumatic brain injury (TBI) management is that noncontrast CT (NCCT) should be the initial triaging diagnostic imaging test of choice for all patients with acute moderate to severe TBI. 1

Initial Assessment and Imaging

• NCCT is highly sensitive for detecting clinically important TBI, defined as severe intracranial injury potentially resulting in death, neurologic intervention, intubation for >24 hours, or admission for >2 days 1
• NCCT effectively detects intracranial hemorrhage, extra-axial fluid collections, skull fractures, radiopaque foreign bodies, cerebral edema, swelling and signs of herniation 1
• Follow-up NCCT is indicated for any trauma patient with neurologic deterioration (Class I recommendation) 1
• Repeat NCCT is supported for patients with moderate to severe TBI and anticoagulated patients with abnormalities on initial NCCT 1
• MRI may be indicated in particular instances when there are persistent neurologic, cognitive, and behavioral symptoms, such as new-onset, progressive, or worsening symptoms (Class I recommendation) 1

Monitoring and Management

• ICP monitoring should be implemented in severe TBI patients with abnormal CT findings, as more than 50% will develop intracranial hypertension 2
• Maintain adequate cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 2
• Systolic blood pressure should be maintained >110 mmHg prior to measuring cerebral perfusion pressure to prevent secondary injury 3
• Severe TBI patients should be managed with a pre-hospital medicalized team and transferred as quickly as possible to specialized centers with neurosurgical facilities 3

Neurological Assessment

• The severity of TBI should be classified using the Glasgow Coma Scale (GCS) score: moderate TBI as GCS scores of 9 to 12, and severe TBI as GCS scores of 3 to 8 1
• Serial GCS scores are more valuable in predicting survival than a single GCS score 1
• The motor component of GCS remains robust even in sedated patients and correlates well with head trauma severity 3
• Repeated neurological examinations should be performed to detect secondary neurological deterioration 3

Management of Complications

• Elevate head of bed to 20-30° to assist venous drainage and minimize edema formation 2
• Control ventilation to maintain PaCO2 between 35-40 mmHg during routine management 2
• Maintain PaO2 between 60-100 mmHg to prevent secondary brain injury 2
• For multiple trauma with TBI, management of life-threatening injuries should be prioritized while avoiding secondary brain injury 3

Common Pitfalls to Avoid

• Hypotension (systolic BP <110 mmHg) should be avoided as it significantly worsens outcomes in TBI patients 3
• Daily interruption of sedation may be harmful in TBI patients with signs of high ICP 2
• Corticosteroids have not shown benefit in TBI and are not recommended for ICP control 2
• Hyperoxia after stabilization should be avoided as it may worsen outcomes 3
• Biomarkers should not be used in clinical routine for initial TBI severity assessment as their utility remains uncertain 3
• The routine practice of repeat NCCT is not supported for patients with mild TBI with negative results on initial NCCT (Class III recommendation) 1