From the Guidelines
Traumatic Brain Injury (TBI) management should prioritize immediate medical attention, stabilization of vital signs, and prevention of secondary injury, with treatment depending on severity, as stated in the 2023 clinical policy approved by the American College of Emergency Physicians (ACEP) board of directors 1.
TBI Overview
TBI is a complex and heterogeneous disease, and a major cause of death and disability globally, with approximately 223,135 TBI-related hospitalizations in 2019 and 64,362 TBI-related deaths in 2020 in the United States alone 1. The initial severity of a TBI may range from “mild” to “severe”, with mild TBI (concussion) typically requiring rest and symptom management, while moderate to severe TBI needs immediate medical attention and often intensive care.
Management and Treatment
Initial management focuses on stabilizing vital signs, preventing secondary injury, and maintaining adequate brain perfusion. Medications may include analgesics for pain (acetaminophen or NSAIDs), anti-seizure drugs if seizures occur (levetiracetam 500-1000mg twice daily or phenytoin 300mg daily), and in severe cases, osmotic diuretics like mannitol (0.25-1g/kg IV) to reduce intracranial pressure 1. Targeted temperature control (TTC) is also a crucial aspect of TBI management, as fever is a prevalent occurrence with heterogenous underlying causes, and it may contribute to secondary injury, with some studies suggesting that TTC can modulate important physiological parameters such as cerebral metabolism and ICP 1.
Rehabilitation and Prevention
Physical, occupational, speech, and cognitive therapy are crucial for rehabilitation, with recovery time varying greatly from weeks to years depending on injury severity. Prevention is key through measures like wearing helmets during high-risk activities, using seatbelts, and removing fall hazards. TBI can cause long-term complications including cognitive impairment, personality changes, and increased risk of neurodegenerative diseases, making proper initial management and rehabilitation essential for optimizing outcomes.
Key Considerations
- Approximately 70% to 90% of patients with a head injury and TBI presenting to the ED will be diagnosed with mild traumatic brain injury (mTBI) 1.
- The costs for all severity levels of TBI are not purely limited to economics, but also include dynamic societal, psychosocial, physical, mental, medicolegal, and other quality of life factors that are often challenging to quantify 1.
- TBI is not solely an acute problem, with the lifetime economic cost of TBI, including direct and indirect costs, estimated to be 76.5 billion dollars in the United States in 2010 1.
From the Research
Definition and Prevalence of TBI
- Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations 2
- TBI can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS) 3
Prehospital Management of TBI
- The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity 2
- Prehospital interventions are targeted at reducing secondary injury while optimizing cerebral physiology 2
- Patient management strategies include indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation 2
Treatment of Elevated Intracranial Pressure
- Hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce intracranial pressure (ICP) 4
- Mannitol is considered the gold standard hyperosmolar agent, but HTS is increasingly used in this setting 4
- Studies have compared the efficacy of mannitol to HTS in severe TBI, with some finding that HTS is more effective in ICP management 5
- The choice between mannitol and HTS as a first-line treatment for elevated ICP caused by TBI is not clear, but HTS may be preferred for refractory intracranial hypertension 5
Management and Challenges of Severe TBI
- Severe TBI should be managed by avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated 3
- Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP) and/or decreasing ICP 3
- Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization 3