What is the management of traumatic brain injury?

Traumatic Brain Injury Management

Initial Assessment and Severity Classification

Severe TBI patients must be managed by a prehospital medicalized team and transferred immediately to a specialized neurosurgical center, as this approach significantly reduces mortality and improves neurological outcomes. 1

• Classify severity using Glasgow Coma Scale (GCS): severe (GCS ≤8), moderate (GCS 9-13), mild (GCS 14-15), with the motor component being most reliable in sedated patients 2
• Assess pupil size and reactivity repeatedly during initial phase, as these are critical prognostic factors 2
• Perform brain and cervical CT scan without delay in all severe and moderate TBI patients 1, 2

Hemodynamic Management - Critical Priority

Maintain systolic blood pressure >110 mmHg at all times, as even a single episode of hypotension below this threshold markedly increases mortality. 1, 3

• A single episode of systolic blood pressure <90 mmHg during early TBI phase significantly worsens neurological outcome 1
• Use vasopressors immediately if hypotension develops rather than waiting for fluid resuscitation 3
• Avoid hypotensive sedative agents during induction and maintenance of sedation 1, 3
• Maintain mean arterial pressure ≥80 mmHg in severe TBI 2
• The combination of hypotension and hypoxemia (SaO₂ <90%) carries a 75% mortality rate 2

Airway and Ventilation Control

• Intubate early if GCS is compromised or risk of deterioration exists 3
• Maintain end-tidal CO₂ between 30-35 mmHg prior to obtaining arterial blood gas samples 1
• Monitor end-tidal CO₂ continuously to prevent both hypercapnia and hypocapnia 3
• Adjust mechanical ventilation to facilitate central venous return 3

Imaging Strategy

Perform brain and cervical CT with bone windows immediately upon arrival to identify primary lesions and guide neurosurgical intervention. 1, 2

• Use double fenestration (central nervous system and bone windows) to fully characterize injuries 1, 3
• Obtain CT angiography of supra-aortic and intracranial vessels early in patients with risk factors for traumatic arterial dissection 1, 3
• Basilar skull fractures are a specific high-risk factor requiring CT angiography 3
• Repeat CT at 6-12 hours if initial scan shows associated intracranial injury 3

Neurosurgical Consultation and Intervention

Immediate neurosurgical evaluation is required for acute subdural/epidural hematoma, multiple hemorrhagic contusions, significant mass effect or midline shift, or deteriorating neurological examination. 3

Early phase neurosurgical indications include: 2

• Evacuation of symptomatic extradural hematoma
• Evacuation of significant acute subdural hematoma
• Drainage of acute hydrocephalus
• Closure of displaced open skull fracture

Intracranial Pressure Management

For persistent intracranial hypertension despite sedation and correction of secondary insults: 2

• Perform external ventricular drainage as first-line intervention
• Use osmotic diuretics (mannitol) to reduce intracranial pressure
• Administer hypertonic saline for clinical transtentorial herniation
• Consider decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion

Monitoring and Admission

• Admit all patients with basilar skull fractures for close neurological observation with serial examinations, even if GCS is 15 3
• Monitor for delayed complications including vascular injury/dissection 3
• Transcranial Doppler can assess brain perfusion; concerning findings include diastolic flow velocity <20 cm/s and pulsatility index >1.4 1, 2

Critical Pitfalls to Avoid

• Do NOT use corticosteroids for TBI management, as they provide no benefit on mortality or neurological outcomes 2
• Do NOT use biomarkers in clinical routine to assess initial severity, as uncertainties remain regarding normal ranges and clinical utility 1
• Do NOT discharge patients with basilar skull fractures without adequate observation, even with GCS 15 3
• Do NOT miss associated vascular injuries—always obtain CT angiography in high-risk fracture patterns 3
• Do NOT allow any episode of arterial hypotension; prevention is critical through continuous sedation rather than boluses and immediate correction of hypovolemia 1