What is the management approach for a patient with a traumatic head injury?

Management of Traumatic Head Injury

Immediately secure the airway through endotracheal intubation and mechanical ventilation, maintain systolic blood pressure >110 mmHg using vasopressors without delay, and obtain urgent non-contrast CT of the brain to guide neurosurgical intervention. 1, 2

Initial Assessment and Severity Stratification

• Assess severity using the Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity—these are the most robust predictors of 6-month neurological outcome validated in studies of over 15,000 patients. 3, 4
• Document each component of the Glasgow Coma Scale separately (Eye-Verbal-Motor) according to the original description. 3
• Age, initial GCS, and pupillary findings remain the key prognostic factors even in contemporary studies. 3, 4

Pre-Hospital and Emergency Department Airway Management

Airway control is the absolute priority and must begin in the pre-hospital period. 1, 2

• Perform endotracheal intubation and mechanical ventilation immediately for all severe TBI patients. 1, 2
• Confirm correct tube placement through end-tidal CO2 monitoring—this is essential and non-negotiable. 1, 2
• Monitor end-tidal CO2 continuously to maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia. 1, 2
• Use rapid sequence intubation with direct laryngoscopy as the standard approach. 5

Hemodynamic Management

Maintain systolic blood pressure >110 mmHg from the moment of first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome. 1, 2

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 1, 2
• Once ICP monitoring is available, target cerebral perfusion pressure ≥60 mmHg, adjusting based on individual autoregulation status. 1

Critical Pitfall to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors—this is a common error that significantly worsens outcomes. 2

Imaging Strategy

• Obtain non-contrast CT of the brain and cervical spine immediately without any delay to guide neurosurgical procedures and monitoring techniques. 1, 2
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone). 1, 2
• CT is the primary modality for detecting surgically treatable lesions in the acute setting. 4, 6

Neurosurgical Intervention Criteria

Perform surgical evacuation for the following indications: 1, 2

• Symptomatic extradural hematoma (regardless of location)
• Acute subdural hematoma with thickness >5mm and midline shift >5mm
• Brain contusions with mass effect
• Acute hydrocephalus requiring drainage
• Open displaced skull fracture
• Closed displaced skull fracture with brain compression

Intracranial Pressure Monitoring and Management

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy. 1, 4
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 4
• Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension. 1

Sedation Management

• Use propofol administered by continuous infusion (not bolus) in combination with normocapnia to decrease intracranial pressure. 1
• Never use bolus sedation instead of continuous infusions—this causes hemodynamic instability and is a critical error. 1, 2
• Avoid hypotensive sedative agents. 1

Coagulation Management

• Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes. 1
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio if needed, then modify based on laboratory values. 1

Supportive Care Measures

• Implement detection and prevention strategies for post-traumatic seizures. 1, 2, 4
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1, 2, 4
• Consider increasing PEEP from 0 to 5-15 cm H₂O, which is associated with decreased ICP and improved cerebral perfusion pressure. 1

Transport and Transfer

• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility—rapid transport to definitive care is essential. 1, 2, 7
• The emphasis during transport should be prevention of secondary CNS injury through airway stabilization, proper ventilation/oxygenation, and adequate circulation. 7

Polytrauma Considerations

• In patients with multiple trauma and severe TBI, coordinate management to address both brain injury and systemic injuries while maintaining physiological targets necessary to prevent secondary brain injury. 4

Palliative Care

• 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. 1