What is the best approach to manage a patient with Traumatic Brain Injury (TBI) who is unable to communicate?

Management of TBI Patients Unable to Communicate

For TBI patients unable to communicate their concerns, immediately establish airway control through endotracheal intubation with continuous end-tidal CO2 monitoring, maintain systolic blood pressure >110 mmHg using vasopressors without delay, obtain urgent non-contrast head CT, and implement intracranial pressure monitoring to guide therapy—since neurological assessment is not feasible in these patients. 1, 2

Immediate Stabilization Priorities

Airway Management

• Perform tracheal intubation and mechanical ventilation as the absolute priority, beginning from the pre-hospital period if the patient cannot protect their airway 1, 3
• Monitor end-tidal CO2 continuously to confirm correct tube placement and maintain PaCO2 within normal range, as hypocapnia causes cerebral vasoconstriction and brain ischemia 1, 3
• Avoid hyperventilation except as a temporary measure for clinical herniation (target PaCO2 30-35 mmHg), as the benefit is short-lived 4

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1, 3
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, which have delayed hemodynamic effects 1, 3
• Avoid hypotensive sedative agents and use continuous infusions instead of boluses to prevent hemodynamic instability 1

Neurological Monitoring When Assessment Is Not Feasible

Intracranial Pressure Monitoring

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy 2, 1
• Place ICP monitoring when initial CT scan shows abnormalities (compressed basal cisterns, midline shift >5mm, intracerebral hematoma >25mL, or disappearance of cerebral ventricles) 2
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available, adjusting based on individual autoregulation status 2

Imaging Strategy

• Obtain non-contrast CT of brain and cervical spine immediately without delay to guide neurosurgical procedures 1, 3
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone) 1, 3

Management of Intracranial Hypertension

First-Line Interventions

• Elevate head of bed 20-30° to assist venous drainage 4
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death 1, 4
• Restrict free water, avoid excess glucose administration, minimize hypoxemia and hypercarbia 4
• Use propofol by continuous infusion (not bolus) in combination with mild hypocapnia to decrease ICP independently of blood pressure changes 1

Second-Line Interventions for Refractory ICP

• Administer osmotic diuretics: mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg) 4
• Consider hypertonic saline for clinical transtentorial herniation, which rapidly decreases ICP 4
• Perform external ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary insults 4
• Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension 2, 4

Coagulation Management in Polytrauma

Monitoring and Transfusion

• Maintain platelet count >100,000/mm³ in TBI patients (more stringent than the >50,000/mm³ for polytrauma alone), as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes 2
• Use point-of-care tests (TEG, ROTEM) to rapidly assess hemostasis and guide clinical decision-making, particularly useful for patients on novel oral anticoagulants 2
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio, then modify based on laboratory values 2

Critical Pitfalls to Avoid

• Never delay vasopressor use while waiting for "adequate fluid resuscitation"—even brief hypotension worsens outcomes 1, 3
• Never use sedation boluses instead of continuous infusions, which causes hemodynamic instability 1, 3
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 1, 3
• Do not use corticosteroids (including dexamethasone) for brain swelling in TBI, as randomized trials show no benefit and potential harm (49% mortality with dexamethasone vs 23% with placebo at 21 days) 4

Supportive Measures

• Implement detection and prevention strategies for post-traumatic seizures 1, 3
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal function 1, 3
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes, reduces length of stay, and enhances communication with family members without reducing survival 2