What is the management approach for traumatic brain injury?

Management of Traumatic Brain Injury

Traumatic brain injury requires immediate systematic assessment using the Glasgow Coma Scale, urgent neuroimaging with CT scan, aggressive prevention of secondary brain injury through maintenance of adequate oxygenation and cerebral perfusion, and neurosurgical consultation for patients with surgical lesions or severe injury. 1

Initial Assessment and Severity Classification

• Immediately assess severity using the Glasgow Coma Scale (GCS), focusing specifically on motor response (most robust component), pupillary size, and pupillary reactivity 1, 2
• Classify TBI severity as: Severe (GCS ≤8), Moderate (GCS 9-13), or Mild (GCS 14-15) 1, 2
• Document the complete injury timeline, including any loss of consciousness, lucid intervals, and subsequent deterioration—patients with lucid intervals are at particularly high risk for sudden deterioration from expanding intracranial lesions 3
• Age, initial GCS score, and pupillary assessment are the strongest predictors of neurological outcome at 6 months 1, 2

Immediate Resuscitation Priorities (Prevent Secondary Brain Injury)

The primary goal is preventing secondary brain injury through aggressive management of hypoxia, hypotension, and hypercapnia:

• Secure the airway immediately and ensure adequate oxygenation—hypoxemia significantly increases mortality and worsens neurological outcomes 2, 4
• Maintain systolic blood pressure ≥100 mmHg to ensure adequate cerebral perfusion; never use "permissive hypotension" strategies even in polytrauma patients with hemorrhagic shock 1, 3, 2
• Control ventilation to maintain PaCO₂ between 35-40 mmHg (normocapnia); avoid prolonged hyperventilation as it causes cerebral ischemia 1, 3, 2
• Elevate head of bed to 30 degrees to improve venous drainage and reduce intracranial pressure 1, 3
• Maintain normothermia and treat seizures promptly 1
• Use only isotonic fluids—hypotonic fluids worsen cerebral edema 1, 2

Urgent Neuroimaging

• Obtain urgent CT scan of the head in all TBI patients to identify surgical lesions and guide management 1, 3, 2
• Never delay neuroimaging in patients with a history of lucid interval, even if they currently appear stable—deterioration can be sudden 3, 2

Neurosurgical Consultation and Surgical Indications

Obtain urgent neurosurgical consultation for:

• All patients with severe TBI (GCS ≤8) 1
• Any patient with a history of lucid interval, even if currently stable 3
• Immediate surgical intervention is required for: depressed skull fractures, open skull fractures with CSF leak or brain tissue exposure, epidural hematoma with mass effect, and any expanding intracranial lesion causing midline shift or significant mass effect 1, 3, 2

Intracranial Pressure Monitoring and Management

ICP monitoring is strongly indicated in:

• Severe TBI patients (GCS ≤8) with abnormal CT findings 1, 2
• Consider in moderate TBI patients who experienced a lucid interval 3

ICP Management Targets:

• Maintain ICP <20 mmHg—values of 20-40 mmHg are associated with increased mortality risk 1, 2
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 1, 3

Tiered Approach to Managing Elevated ICP:

1. Ensure adequate sedation and analgesia 1
2. Maintain head of bed elevation at 30 degrees 1
3. Control ventilation (PaCO₂ 35-40 mmHg) 1
4. Maintain normothermia and treat seizures 1
5. Consider osmotic therapy with mannitol (0.25-2 g/kg) for clinical deterioration 3

Special Considerations for Polytrauma

• Balance addressing life-threatening hemorrhage with preventing secondary brain injury—never sacrifice cerebral perfusion for other injuries 1, 3
• Maintain normal coagulation parameters with PT/aPTT <1.5 times normal control during interventions 1, 3
• Avoid hypotonic fluids and prolonged hyperventilation 1

Pediatric-Specific Considerations

• Children require the same urgent neuroimaging and close monitoring as adults 3, 2
• Use the same GCS classification and ICP targets 2
• For mild TBI (concussion), provide comprehensive discharge instructions with warning signs, expected symptom course, and gradual return-to-activity protocols 2
• Never prescribe complete rest beyond the first few days in mild TBI, as this may delay recovery 2

Critical Pitfalls to Avoid

• Never allow hypotension in TBI patients, even with hemorrhagic shock elsewhere 1, 3, 2
• Never use hypotonic fluids that worsen cerebral edema 1, 3, 2
• Never employ prolonged hyperventilation as it causes cerebral ischemia 1, 3, 2
• Never delay neuroimaging in patients with lucid intervals, even if stable 3, 2
• Never assume stability—patients who appear well after initial injury can deteriorate suddenly 3, 2

Long-Term Perspective

TBI should be recognized as a chronic disease process, not merely an acute event, as it increases long-term mortality, reduces life expectancy, and is associated with increased incidences of seizures, neurodegenerative diseases, neuroendocrine dysregulation, and psychiatric disorders that may persist for months to years post-injury 5. This recognition is crucial for appropriate long-term monitoring and management 6, 5.