Head Injury: Treatment and Management
Severe traumatic brain injury patients must be transferred immediately to a specialized neurosurgical center by a prehospital medicalized team, as this approach significantly reduces mortality compared to non-specialized centers. 1, 2
Initial Assessment and Severity Stratification
Classify severity using Glasgow Coma Scale (GCS): severe (GCS ≤8), moderate (GCS 9-13), mild (GCS 14-15). 1, 2
Imaging Requirements by Severity:
Severe and moderate TBI: Perform brain and cervical CT scan immediately without delay using double fenestration (central nervous system and bone windows). 1, 2
Mild TBI (GCS 14-15): CT scan required if any of the following present: signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, retroauricular hematoma, periorbital hematoma), displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulation disorders, or anticoagulant therapy. 1
Hemodynamic Management - Highest Priority for Mortality Reduction
Maintain systolic blood pressure >110 mmHg at all times. Even a single episode below this threshold markedly increases mortality, and episodes <90 mmHg significantly worsen neurological outcomes. 1, 2
Specific interventions to prevent hypotension:
- Avoid hypotensive sedative agents during induction; use continuous sedation rather than boluses. 1, 2
- Correct hypovolemia immediately with fluid resuscitation. 1
- Use vasopressors (phenylephrine or norepinephrine) immediately for rapid correction rather than waiting for delayed effects of fluid or sedative adjustments. 1, 2
- Catecholamines can be initially infused through peripheral IV. 1
- Adjust mechanical ventilation to facilitate central venous return. 1
Maintain mean arterial pressure ≥80 mmHg in severe TBI patients. 1
Airway and Ventilation Control
Perform tracheal intubation in all severe TBI patients (GCS ≤8) with continuous end-tidal CO₂ monitoring, beginning in the prehospital period. This decreases mortality. 1, 2
- Maintain end-tidal CO₂ between 30-35 mmHg prior to obtaining arterial blood gas samples. 1, 2
- Avoid hypocapnia, which induces cerebral vasoconstriction and increases risk of brain ischemia. 1
- Monitor end-tidal CO₂ continuously to confirm correct tube placement and detect changes in cardiac output. 1
Advanced Imaging for Vascular Injury
Perform CT angiography of supra-aortic and intracranial vessels early in patients with the following risk factors for traumatic arterial dissection: 1, 2
- Cervical spine fracture
- Focal neurological deficit unexplained by brain imaging
- Horner syndrome
- LeFort II or III facial fractures
- Basilar skull fractures
- Soft tissue neck lesions
If CT angiography is normal but suspicion remains high, complete with MR angiography or digital subtraction angiography. 1
Neurosurgical Intervention Indications
Early phase neurosurgical indications include: 1, 2
- Evacuation of symptomatic extradural hematoma (any location)
- Evacuation of significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm)
- Drainage of acute hydrocephalus
- Closure of open displaced skull fracture
- Closed displaced skull fracture with brain compression (thickness >5 mm, midline shift >5 mm)
Intracranial Pressure Management Algorithm
For persistent intracranial hypertension despite sedation and correction of secondary insults:
First-line: External ventricular drainage of cerebrospinal fluid. 1, 2
Additional options: Removal of brain contusions with mass effect after first-line treatment failure. 1
Refractory cases: Decompressive craniectomy after multidisciplinary discussion. 1, 2
Monitor intracranial pressure in severe TBI to detect intracranial hypertension. 1
Sedation Considerations
Use continuous sedation rather than boluses to avoid arterial hypotension. 1
Critical caveat: Arterial hypotension can occur with barbiturates, bolus midazolam, or bolus opioids—control systemic hemodynamics carefully when choosing sedative agents and administration methods. 1
No evidence exists that one sedative or opioid agent is superior to another in TBI patients. 1
Monitoring Adjuncts
Transcranial Doppler can assess brain perfusion and predict deterioration: 1, 2
- Concerning findings: diastolic flow velocity <20 cm/s and pulsatility index >1.4 in severe TBI
- In moderate/mild TBI: diastolic velocity <25 cm/s or pulsatility index >1.25 predicts secondary neurological degradation
- Should be part of initial FAST examination
Critical Pitfalls to Avoid
Do NOT use biomarkers (S100b, NSE, UCH-L1, GFAP, MBP, tau protein) in clinical routine to assess initial severity, as uncertainties remain regarding normal ranges and clinical utility. 1, 2
Do NOT allow any episode of arterial hypotension—prevention through continuous sedation and immediate hypovolemia correction is critical. 1, 2
Do NOT use excessive hyperventilation as routine therapy; reserve for clinical deterioration and uncal herniation only. 1
Do NOT discharge patients with basilar skull fractures without adequate observation, even with GCS 15. 2
Do NOT miss associated vascular injuries—always obtain CT angiography in high-risk fracture patterns. 2