What is the initial management for Traumatic Brain Injury (TBI) patients?

Initial Management of Traumatic Brain Injury (TBI) Patients

The initial management of TBI patients must prioritize immediate assessment using the Glasgow Coma Scale (particularly the motor component) and pupillary examination, followed by aggressive prevention and correction of hypotension and hypoxemia, with rapid transfer to a specialized neurosurgical center. 1

Immediate Clinical Assessment

Assess severity using three key parameters: 1

• Glasgow Coma Scale (GCS) - Document all three components (Eye-Verbal-Motor), but the motor response is most critical as it remains reliable even in sedated/intubated patients 1
• Pupillary size and reactivity - Abnormal pupils indicate increased intracranial pressure and predict poor 6-month neurological outcomes 1, 2
• Age - Independent predictor of outcome validated in large studies (IMPACT: 6,681 patients; CRASH: 8,509 patients) 1

Repeat neurological examinations frequently to detect secondary deterioration: 1

• Moderate TBI (GCS 9-13): Every 15-30 minutes initially, then hourly 1
• Any decline of ≥2 points in GCS or new neurological deficit mandates immediate repeat CT scan 1

Critical Physiological Targets - Prevent Secondary Brain Injury

Maintain systolic blood pressure >110 mmHg (or mean arterial pressure ≥80 mmHg): 1, 2

• Even brief episodes of hypotension (SBP <90 mmHg for ≥5 minutes) dramatically increase mortality and morbidity 1
• The combination of hypotension and hypoxemia carries a 75% mortality rate 1

Prevent and aggressively treat hypoxemia (maintain SaO2 >90%): 1

• Hypoxemia occurs in ~20% of TBI patients and significantly worsens 6-month outcomes 1
• Duration of hypoxemic episodes directly correlates with mortality 1

Control ventilation if intubated (target end-tidal CO2: 30-35 mmHg): 1, 2

• Avoid both hypercarbia (increases intracranial pressure) and excessive hyperventilation (causes cerebral vasoconstriction) 1

Neuroimaging Protocol

Obtain immediate non-contrast head CT for: 1

• All severe TBI (GCS ≤8) - mandatory without delay 1
• All moderate TBI (GCS 9-13) - mandatory without delay 1
• Mild TBI (GCS 14-15) with any of: basal skull fracture signs (hemotympanum, Battle's sign, raccoon eyes, CSF leak), displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulopathy, or anticoagulant use 1

CT technique: Use inframillimetric sections with double fenestration (brain and bone windows) 3, 2

Consider CT angiography if: Cervical spine fracture, focal deficits unexplained by brain imaging, or basal skull fractures present 3, 2

Prehospital and Transfer Management

Transfer immediately to a Level I trauma center with neurosurgical capabilities: 1

• Mortality is significantly lower in specialized neurosurgical centers even for patients not requiring surgery 1
• Medically staffed prehospital teams improve outcomes 1

Prehospital intubation decision must be individualized: 4

• More difficult than in-hospital intubation; weigh risks carefully 4
• If performed, use ketamine plus benzodiazepines for hemodynamically unstable patients 4

Adjunctive Assessment Tools

Consider transcranial Doppler (TCD) on arrival: 1, 2

• Concerning findings: diastolic velocity <20-25 cm/s or pulsatility index >1.25-1.4 1, 2
• Can be incorporated into FAST examination protocol 1

Do NOT use biomarkers (S100b, NSE, UCH-L1, GFAP) for routine clinical decision-making: 1

• Insufficient evidence for clinical utility despite associations with outcomes 1

Monitoring Requirements

For moderate TBI (GCS 9-13): 1

• Minimum 24-hour hospital observation mandatory even if CT appears reassuring 3
• High risk of secondary deterioration requiring vigilant monitoring 1

For severe TBI (GCS ≤8): 2, 5

• Consider intracranial pressure monitoring 2, 5
• Monitor for Cushing's triad: hypertension, bradycardia, irregular respirations 2, 5

Critical Pitfalls to Avoid

Never tolerate hypotension or hypoxemia - These are the most preventable causes of secondary brain injury with devastating consequences 1, 4

Do not delay transfer to neurosurgical center - Outcomes are significantly better with early specialized care regardless of surgical need 1

Avoid excessive hyperventilation - Target PaCO2 30-35 mmHg initially; excessive hyperventilation causes harmful cerebral vasoconstriction 1, 2

Do not use corticosteroids - No mortality or neurological benefit demonstrated 2

Recognize that deterioration after initial stability is common - 71% of delayed deteriorations occur within 24 hours, and 81% have mass lesions requiring intervention 2