What is the management of Traumatic Brain Injury (TBI)?

Management of Traumatic Brain Injury

Secure the airway immediately with tracheal intubation and mechanical ventilation while maintaining strict control of PaCO2 (35-40 mmHg) and PaO2 (60-100 mmHg), avoid hypotension at all costs (maintain SBP >110 mmHg), obtain urgent CT imaging, and implement ICP monitoring in severe TBI with abnormal CT findings. 1, 2

Initial Resuscitation and Stabilization

Airway and Ventilation Control

• Perform immediate tracheal intubation for all severe TBI patients (GCS ≤8) to protect the airway and control ventilation. 1
• Monitor end-tidal CO2 (EtCO2) continuously from the pre-hospital phase through ICU care to verify tube placement and maintain appropriate PaCO2. 1
• Maintain PaCO2 between 35-40 mmHg during routine management to avoid cerebral vasoconstriction and ischemia from hypocapnia. 1, 2
• Maintain PaO2 between 60-100 mmHg to ensure adequate cerebral oxygenation. 3, 2, 4
• Reserve temporary hyperventilation (PaCO2 30-35 mmHg) only for acute herniation crises while awaiting definitive intervention. 3, 2

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg (or MAP >80 mmHg) at all times, as hypotension dramatically worsens secondary brain injury and mortality. 3, 2, 4
• Avoid "permissive hypotension" strategies even in polytrauma patients with hemorrhagic shock, as arterial hypotension exacerbates cerebral secondary damage. 2, 4
• Once ICP monitoring is established, maintain cerebral perfusion pressure (CPP) ≥60 mmHg. 2, 4, 5
• Use vasopressors as needed to maintain blood pressure targets while resuscitating with fluids. 5

Severity Classification and Risk Stratification

Glasgow Coma Scale Assessment

• Classify TBI severity using GCS: severe (GCS ≤8), moderate (GCS 9-13), mild (GCS 14-15). 2, 6
• Pay particular attention to the motor response component and evaluate pupillary size and reactivity. 3
• Perform repeated neurological examinations every 15-30 minutes initially in moderate TBI patients to detect secondary deterioration. 3
• Any decrease of ≥2 points in GCS or new secondary neurological deficit mandates immediate repeat CT scan. 3

CT Imaging Criteria for High Risk

• Obtain brain and cervical spine CT scan without delay in all suspected TBI patients. 3
• Suspect intracranial hypertension when major criteria are present: compressed basal cisterns, midline shift >5mm, or non-evacuated mass lesion. 2
• Minor criteria (requiring two to suspect intracranial hypertension): GCS motor score ≤4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall diffuse injury grade II. 2
• Compression of basal cisterns is the best CT sign to predict intracranial hypertension. 1

Intracranial Pressure Monitoring and Management

Indications for ICP Monitoring

• Place ICP monitor in all severe TBI patients (GCS ≤8) with abnormal CT findings, as >50% will develop intracranial hypertension. 1, 2
• Consider ICP monitoring in moderate TBI patients with high-risk CT features or inability to perform serial neurological exams. 1
• ICP of 20-40 mmHg increases mortality risk 3.95-fold; ICP >40 mmHg increases mortality risk 6.9-fold. 2

First-Tier ICP Management

• Elevate head of bed 30 degrees to facilitate venous drainage. 3
• Provide adequate sedation and analgesia, though no specific agent has proven superior in TBI. 1
• Avoid bolus administration of midazolam, opioids, or barbiturates due to risk of arterial hypotension. 1
• Maintain CPP ≥60 mmHg as the primary target. 2, 4
• Correct all secondary brain insults including hypotension, hypoxemia, hyperthermia, and hypo-osmolarity. 3

Second-Tier ICP Management

• Administer osmotherapy with hypertonic saline or mannitol for refractory intracranial hypertension. 2
• Avoid hypo-osmolar fluids that worsen cerebral edema. 3, 2
• Consider external ventricular drainage (EVD) for persistent intracranial hypertension despite first-tier measures. 1, 4
• EVD can dramatically reduce ICP even with small CSF volumes removed and can be placed using neuronavigation. 1

Third-Tier ICP Management

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion. 1
• Large unilateral temporal craniectomy (>100 cm²) with dural expansion reduces mortality (26.9% vs 48.9%) but increases severe disability risk. 1, 2
• Unilateral craniectomy improved good outcomes (GOS 4-5) to 40-57% vs 28-32% in controls. 1
• Avoid bifrontal craniectomy for diffuse injuries, as the DECRA study showed worse outcomes (70% poor outcome vs 51% in controls). 1
• Age >60-70 years is generally an exclusion criterion for decompressive craniectomy; decisions must be individualized. 1

Neurosurgical Interventions

Immediate Surgical Indications

• Remove symptomatic epidural hematoma regardless of location. 1
• Evacuate acute subdural hematoma if thickness >5mm with midline shift >5mm. 1
• Drain acute hydrocephalus emergently. 1
• Close open displaced skull fractures. 1
• Repair closed displaced skull fractures with brain compression (thickness >5mm, midline shift >5mm). 1
• Consider removing brain contusions with mass effect after failure of first-line ICP management. 1

Transfer to Specialized Centers

• Immediately transfer all TBI patients requiring neurosurgical intervention to specialized centers with neurosurgical facilities. 3
• This is particularly critical for patients with lucid intervals who may have epidural hematomas requiring urgent evacuation. 3

Coagulation Management

Reversal of Anticoagulation

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage and >100,000/mm³ for neurosurgical interventions including ICP probe insertion. 2, 4
• Keep PT/aPTT <1.5 times normal control during interventions. 2, 4
• Utilize point-of-care coagulation tests (TEG, ROTEM) when available to guide management. 2, 4

Transfusion Thresholds

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery. 4
• During massive transfusion protocol, use RBC:Plasma:Platelets ratio of 1:1:1, then adjust based on laboratory values. 4

Special Considerations

TBI with Polytrauma

• In exsanguinating patients, control life-threatening hemorrhage first before addressing brain injuries. 4
• Perform urgent neurological evaluation immediately after hemorrhage control, including pupils, GCS motor score, and brain CT. 4
• Consider simultaneous multisystem surgery (SMS) protocols for patients requiring both hemorrhage control and emergency neurosurgery. 4
• SMS has been associated with shorter times to CT/surgery and fewer unfavorable outcomes at 6 months. 4

Lucid Interval Recognition

• Recognize that lucid interval (brief unconsciousness, lucid period, then rapid deterioration) is characteristic of epidural hematoma. 3
• This represents a critical window for intervention before potentially fatal deterioration. 3
• Never delay imaging or neurosurgical consultation in patients with history of lucid interval. 3

Sedation Management

• Follow standard ICU sedation guidelines for stabilized brain-injured patients. 1
• Avoid daily interruption of sedation in patients with signs of high ICP, as this may be harmful. 3
• No specific sedative or opioid agent has proven superior for TBI patients. 1

Critical Pitfalls to Avoid

• Never allow hypotension (SBP <110 mmHg), as this is the most preventable cause of secondary brain injury. 3, 2, 4
• Do not use corticosteroids for ICP control in TBI patients, as they are ineffective and potentially harmful. 3
• Avoid routine hyperventilation (PaCO2 <35 mmHg), reserving it only for acute herniation. 1, 2
• Do not use hypo-osmolar fluids that worsen cerebral edema. 3, 2
• Never delay neurosurgical consultation for patients with surgical lesions or refractory ICP elevation. 3

Advanced Neuromonitoring

Transcranial Doppler

• Use transcranial Doppler to assess brain hemodynamics, particularly in patients at risk for secondary deterioration. 3
• Diastolic blood flow velocity <25 cm/s or pulsatility index >1.3 is associated with poor outcome. 3