What are the guidelines for managing traumatic brain injury?

Management of Traumatic Brain Injury

Severe traumatic brain injury (GCS ≤8) requires immediate airway control with tracheal intubation and mechanical ventilation, strict avoidance of hypotension (maintain SBP >110 mmHg), and meticulous control of oxygenation and ventilation to prevent secondary brain injury. 1

Initial Resuscitation and Stabilization

Airway Management

• Perform immediate tracheal intubation for all severe TBI patients (GCS ≤8) to protect the airway and control ventilation 1
• Patients with GCS ≤8, deteriorating conscious level (fall in GCS ≥2 points or motor score ≥1 point) requiring transfer should undergo tracheal intubation 2
• Monitor end-tidal CO2 (EtCO2) continuously from pre-hospital phase through ICU care to verify tube placement and maintain appropriate PaCO2 1

Ventilation Targets

• Maintain PaCO2 between 35-40 mmHg during routine management to avoid cerebral vasoconstriction and ischemia from hypocapnia 1
• Maintain PaO2 between 60-100 mmHg to ensure adequate cerebral oxygenation 1
• Reserve temporary hyperventilation (PaCO2 30-35 mmHg) ONLY for acute herniation crises while awaiting definitive intervention 1
• Routine hyperventilation below 35 mmHg should be avoided as it causes cerebral vasoconstriction and worsens ischemia 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg (or MAP >80 mmHg) at all times, as hypotension dramatically worsens secondary brain injury and mortality 1
• Hypotension is the most preventable cause of secondary brain injury and must be avoided 1
• Avoid "permissive hypotension" strategies even in polytrauma patients with hemorrhagic shock, as arterial hypotension exacerbates cerebral secondary damage 1, 3
• Once ICP monitoring is established, maintain cerebral perfusion pressure (CPP) ≥60 mmHg 1
• Resuscitation and stabilization should be underway before transfer; avoid transfer of hypotensive or hypoxic patients 2

Severity Classification and Risk Stratification

• Classify TBI severity using Glasgow Coma Scale: severe (GCS ≤8), moderate (GCS 9-13), mild (GCS 14-15) 1
• Perform repeated neurological examinations every 15-30 minutes initially in moderate TBI patients to detect secondary deterioration 1
• Any decrease of ≥2 points in GCS or new secondary neurological deficit mandates immediate repeat CT scan 1

Intracranial Pressure Monitoring

Indications for ICP Monitoring

• Place ICP monitor in all severe TBI patients (GCS ≤8) with abnormal CT findings, as >50% will develop intracranial hypertension 1
• Consider ICP monitoring in moderate TBI patients with high-risk CT features or inability to perform serial neurological exams 1
• ICP monitoring is indicated when neurological assessment is not feasible 2

CT Scan Risk Factors for Intracranial Hypertension

• Compression or disappearance of basal cisterns (>70% will have ICP >30 mmHg) 2
• Brain midline shift >5 mm 2
• Intracerebral hematoma volume >25 mL 2
• Traumatic subarachnoid hemorrhage 2
• Disappearance of cerebral ventricles 2

Clinical Significance of ICP Elevation

• ICP of 20-40 mmHg increases mortality risk 3.95-fold 1
• ICP >40 mmHg increases mortality risk 6.9-fold 1
• The incidence of high ICP in severe TBI varies between 17-88% 2

Neurosurgical Interventions

• Remove symptomatic epidural hematoma regardless of location 1
• Evacuate acute subdural hematoma if thickness >5mm with midline shift >5mm 1
• Drain acute hydrocephalus emergently 1
• Decompressive craniectomy for refractory intracranial hypertension reduces mortality (26.9% vs 48.9%) but may increase poor neurological outcomes 2
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique 2

Coagulation Management

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage 1
• Maintain platelet count >100,000/mm³ for neurosurgical interventions including ICP probe insertion 1
• Keep PT/aPTT <1.5 times normal control during interventions 1
• Utilize point-of-care coagulation tests (TEG, ROTEM) when available to guide management 1, 3

Transfer Guidelines

Pre-Transfer Requirements

• Designated consultants in referring hospitals and neuroscience units should have overall responsibility for transfer organization 2
• Local guidelines should be drawn up between referring hospitals, neuroscience units, and local ambulance services 2
• Transfer of responsibility for patient care should be agreed by both parties 2
• Although transfer is often urgent, resuscitation and stabilization must be underway before transfer 2

Transfer Team Requirements

• Patients with brain injury should be accompanied by a clinician with appropriate training and experience in transfer of patients with acute brain injury 2
• Monitoring during transport should adhere to published guidelines 2
• The transfer team should possess a mobile phone for urgent communication 2

Special Considerations for Stroke Patients

• Patients with acute ischemic stroke for thrombectomy should be transferred without delay 2
• Those with anterior circulation stroke rarely need airway intervention 2

Management of Polytrauma with TBI

Prioritization in Exsanguinating Patients

• In exsanguinating patients, control life-threatening hemorrhage first before addressing brain injuries 1, 3
• Perform urgent neurological evaluation immediately after hemorrhage control, including pupils, GCS motor score, and brain CT 1, 3
• Consider simultaneous multisystem surgery (SMS) protocols for patients requiring both hemorrhage control and emergency neurosurgery 1, 3

Blood Product Management in Polytrauma

• Transfuse red blood cells for hemoglobin level <7 g/dL during interventions 3
• During massive transfusion protocol, transfuse RBCs/Plasma/PLTs at ratio of 1:1:1, with subsequent adjustments based on laboratory values 3
• Maintain higher platelet thresholds (>100,000/mm³) for emergency neurosurgery 3

Critical Pitfalls to Avoid

• Never allow hypotension (SBP <110 mmHg), as this is the most preventable cause of secondary brain injury 1
• Do not use corticosteroids for ICP control in TBI patients, as they are ineffective and potentially harmful 1
• Avoid routine hyperventilation (PaCO2 <35 mmHg), reserving it only for acute herniation 1
• Do not use hypo-osmolar fluids that worsen cerebral edema 1
• Do not transfer hypotensive or hypoxic patients before stabilization 2
• Avoid emergency extracranial surgery (except life-threatening conditions) when signs of high ICP are present on brain CT scan 2

Quality Improvement

• Education, training, and continuous audit are crucial and help maintain standards of transfer 2
• Local guidelines should be consistent with national guidelines 2
• High-quality transfer of patients with brain injury is empirically associated with better outcomes 2