From the Guidelines
Traumatic Brain Injury (TBI) management should prioritize prevention of secondary injury, with immediate medical attention and intensive care for moderate to severe cases, and rest and symptom management for mild TBI (concussion), as stated in the 2023 clinical policy approved by the American College of Emergency Physicians (ACEP) board of directors 1.
Key Considerations
- TBI can result from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile.
- The initial severity of TBI may range from mild to severe, with mild TBI (concussion) typically requiring rest and symptom management, while moderate to severe TBI necessitates immediate medical attention and often intensive care.
- Initial management focuses on stabilizing vital functions, preventing secondary injury, and may include medications like anti-seizure drugs and analgesics for pain.
Treatment and Management
- Recovery involves a multidisciplinary approach including physical, occupational, and speech therapy, with gradual return to activities.
- Long-term complications may include cognitive deficits, mood disorders, and seizures, requiring ongoing management.
- Prevention strategies include wearing appropriate protective gear during sports and activities, using seatbelts, and making living spaces fall-proof for vulnerable individuals.
Recent Guidelines and Recommendations
- The 2023 clinical policy approved by the ACEP board of directors provides guidance on the management of adult patients presenting to the emergency department with mild traumatic brain injury 1.
- Targeted temperature control (TTC) is a complex intervention that aims to control body or brain temperature to prevent further brain injury and improve neurological outcome, with its role in improving long-term outcome and appropriate indications, targets, and duration currently being explored 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 has been called the 'silent epidemic' of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide 3.
Management of TBI
- The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation 3.
- The aims and objectives of TBI management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue 3.
- Prehospital interventions targeted at reducing secondary injury while optimizing cerebral physiology are crucial in the management of TBI 2.
- Hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce intracranial pressure (ICP) in TBI patients 4.
Treatment Options for TBI
- Mannitol and HTS are two commonly used hyperosmolar agents in the treatment of TBI, with similar effects in reducing ICP 5, 4.
- The choice between mannitol and HTS may depend on individual patient conditions, with HTS associated with a longer duration of effect and shorter ICU stay 5.
- Other treatment options for TBI include surgical evacuation of mass lesions, cerebrospinal fluid (CSF) drainage, and decompressive craniectomy (DC) 6.
Challenges and Future Directions in TBI Management
- Severe TBI remains a devastating injury with challenging long-term outcomes, and more research is required to improve management and treatment options 6.
- New modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize cerebral blood flow (CBF) in TBI patients 6.