What are the treatment options for Traumatic Brain Injury (TBI)?

Treatment for Traumatic Brain Injury

The treatment of TBI requires immediate systematic assessment using the ABCDE approach (airway, breathing, circulation, disability, exposure), followed by targeted interventions to prevent secondary brain injury through control of intracranial pressure, maintenance of adequate cerebral perfusion pressure, and avoidance of systemic insults including hypotension, hypoxia, and hypercapnia. 1

Initial Assessment and Severity Stratification

Assess severity using the Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity—these are the most robust predictors of 6-month neurological outcome. 1 The motor component remains reliable even in sedated patients, while eye and verbal responses are often obscured by prehospital intubation and sedation. 1

Age, initial Glasgow Coma Scale, and pupillary findings are validated prognostic factors from large studies including over 15,000 patients. 1

Prehospital and Emergency Management

Airway Management

• Perform rapid sequence intubation with adequate sedation and muscle relaxation to prevent increases in intracranial pressure during the procedure. 2
• Use manual-in-line-stabilization (MILS) technique during intubation, as C-spine injury frequently accompanies TBI. 2
• Video laryngoscopes (AirWay Scope®, AirTraq, Glidescope®) are preferred over direct laryngoscopy as they reduce cervical spine movement at the occiput-C1 and C2-C5 levels while improving visualization. 2

Physiological Targets

• Maintain normocapnia and mild hyperoxemia to prevent secondary brain injury. 2
• Avoid hypotension and hypoxia at all costs—these are the most critical systemic insults that worsen outcome. 1, 3
• Target euvolemia rather than fluid restriction. 3

Imaging Strategy

Obtain non-contrast CT immediately in all patients with severe TBI. 1 CT is the primary modality for detecting surgically treatable lesions including extradural hematomas, which characteristically respect suture lines due to dural adherence at these locations. 4 This imaging characteristic helps differentiate extradural from subdural hematomas, which cross suture lines. 4

Intracranial Pressure Management

Monitoring

Implement cerebral monitoring in severe TBI patients to guide ICP-directed therapy. 1 The goal is to maintain adequate cerebral perfusion pressure (CPP), which serves as a surrogate for cerebral blood flow. 3

Medical Management of Elevated ICP

CPP can be maintained by increasing mean arterial pressure, decreasing ICP, or both. 3

Osmotic Therapy

• Mannitol is indicated for reduction of intracranial pressure and brain mass in both adults and pediatric patients. 5
• Mannitol works by increasing plasma osmotic pressure, inducing movement of intracellular water to extracellular and vascular spaces. 5
• Approximately 80% of a mannitol dose appears in urine within 3 hours in patients with normal renal function. 5
• Caution: In patients with renal impairment, mannitol's elimination half-life extends from 0.5-2.5 hours to approximately 36 hours, requiring dose adjustment. 5

Temperature Control

Targeted temperature control (TTC) should be used to prevent fever and maintain normothermia, as hyperthermia increases risk of complications and unfavorable outcomes including death. 1 TTC modulates cerebral metabolism and ICP, though optimal targets and duration remain areas of ongoing investigation. 1

Neurosurgical Intervention

Surgical evacuation is indicated for symptomatic extradural hematomas regardless of location. 4 The anatomical restriction of EDHs by suture lines can lead to rapid pressure accumulation in a limited space, potentially accelerating neurological deterioration. 4 Conservative management may be considered only for smaller hematomas with minimal symptoms. 4

Supportive Care Measures

Seizure Prophylaxis

Implement detection and prevention strategies for post-traumatic seizures. 1 This is a distinct management priority in the first 24 hours.

Metabolic Optimization

• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1
• Provide appropriate nutritional support. 3

Prophylaxis

• Initiate venous thromboembolism prophylaxis. 3
• Provide stress ulcer prophylaxis. 3

Polytrauma Considerations

In patients with multiple trauma and severe TBI, coordinate management to address both the brain injury and systemic injuries while maintaining the physiological targets necessary to prevent secondary brain injury. 1 The brain remains susceptible to secondary injury from processes extending beyond the primary injury zone, including ischemia, edema, herniation, and altered metabolism. 1

Pediatric Specificities

Pediatric TBI management follows similar principles but requires specific modifications in dosing, monitoring thresholds, and developmental considerations. 1