What is the appropriate management and treatment for a patient with traumatic brain injury?

Management of Traumatic Brain Injury

The management of traumatic brain injury requires immediate assessment using the Glasgow Coma Scale (particularly the motor component) and pupillary examination, followed by aggressive prevention of secondary brain injury through airway control, maintenance of normocapnia (PaCO₂ 35-40 mmHg), avoidance of hypotension, urgent neuroimaging, and neurosurgical consultation when indicated. 1, 2

Initial Assessment and Severity Classification

• Assess severity immediately using the Glasgow Coma Scale, focusing specifically on the motor response component, along with pupillary size and reactivity as these are the most robust predictors of 6-month neurological outcome 1, 2, 3
• Classify severity as: Severe (GCS ≤8), Moderate (GCS 9-13), or Mild (GCS 14-15) 2, 3
• Document each GCS component separately (Eye-Verbal-Motor) according to the original description, though the motor component remains most reliable in sedated or intubated patients 1
• Age, initial GCS score, and pupillary examination are validated prognostic factors from large cohort studies including over 15,000 patients 1, 2

Immediate Resuscitation Priorities

Airway and Ventilation Management

• Secure the airway through tracheal intubation in severe TBI to control ventilation and prevent hypoxemia, which significantly increases mortality 1, 2
• Maintain normocapnia with PaCO₂ between 35-40 mmHg (or EtCO₂ 30-35 mmHg initially) throughout the prehospital and hospital phases 1, 2, 3
• Monitor end-tidal CO₂ continuously, even during prehospital transport, to verify correct tube placement and maintain appropriate ventilation 1
• Never employ prolonged hyperventilation as hypocapnia induces cerebral vasoconstriction and causes brain ischemia 1, 2, 4

Hemodynamic Management

• Maintain adequate blood pressure to ensure cerebral perfusion—never allow hypotension in TBI patients, even when hemorrhagic shock is present elsewhere 2, 3, 4
• Target systolic blood pressure ≥100 mmHg and cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available 4
• Avoid hypotonic fluids that worsen cerebral edema 2

Neuroimaging Strategy

• Obtain an urgent CT scan of the head immediately in all severe TBI patients, even those who appear stable or are currently lucid 2, 3, 4
• Never delay neuroimaging in patients with a history of lucid interval, as deterioration can be sudden 2, 4
• CT imaging guides neurosurgical decision-making and identifies surgical lesions requiring immediate intervention 3

Neurosurgical Consultation and Intervention

Immediate Neurosurgical Consultation Required For:

• Symptomatic extradural hematoma (regardless of location) 1
• Significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm) 1
• Depressed skull fractures 2, 3, 4
• Open skull fractures with CSF leak or brain tissue exposure 2, 3, 4
• Epidural hematoma with mass effect 2, 3, 4
• Any expanding intracranial lesion causing midline shift or significant mass effect 3, 4
• Acute hydrocephalus requiring drainage 1

Surgical Interventions

External Ventricular Drainage:

• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1
• Small volume CSF removal can markedly reduce intracranial pressure 1

Decompressive Craniectomy:

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion 1
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most common technique 1
• Evidence shows reduced mortality (26.9% vs 48.9%) but increased poor neurological outcomes (8.5% vs 2.1%) compared to medical management alone 1
• This creates a critical trade-off: craniectomy saves lives but may result in more survivors with severe disability 1

Intracranial Pressure Monitoring and Management

ICP Monitoring Indications:

• Implement ICP monitoring in severe TBI (GCS ≤8) with abnormal CT findings 2, 3
• Consider for moderate TBI with history of lucid interval 4
• Target ICP <20 mmHg, as values of 20-40 mmHg are associated with increased mortality risk 2, 3
• Consider lower ICP thresholds in younger children, as physiologic ICP values are age-dependent 3

Tiered ICP Management:

First-Tier Interventions:

• Adequate sedation and analgesia (no single agent proven superior, but avoid boluses causing hypotension) 1, 4
• Maintain normothermia—therapeutic hypothermia does not improve neurological outcomes 5
• Treat seizures if present 4

Second-Tier Interventions:

• Osmotic therapy with mannitol (0.25-2 g/kg) for clinical deterioration, though no clear outcome benefit for any individual osmotherapy agent has been demonstrated 4, 5
• Monitor renal function closely with mannitol use, particularly in pediatric patients 3

Sedation and Analgesia

• No evidence exists that one sedative or opioid agent provides more efficacy than another in TBI patients 1
• Avoid boluses of midazolam, opioids, or barbiturates that can cause arterial hypotension 1
• Pay careful attention to systemic hemodynamics when choosing drugs and administration modalities 1
• Insufficient data exist for halogenated agents and dexmedetomidine in TBI patients 1

Seizure Management

• Levetiracetam appears as effective as phenytoin for seizure management, though optimal dosing remains unclear 5
• Treat seizures promptly as part of first-tier ICP management 4

Additional Pharmacologic Considerations

• Tranexamic acid may reduce all-cause mortality within 24 hours of injury based on large randomized controlled trial data 5
• No clear outcome benefit has been demonstrated for any specific osmotherapy agent regarding mortality or neurological recovery 5

Airway Management Timing

• Early tracheostomy (<7 days from injury) reduces ventilator-associated pneumonia incidence and decreases duration of mechanical ventilation, critical care stay, and hospital stay 5
• This represents a significant quality-of-life consideration for severe TBI patients requiring prolonged ventilation 5

Management of Mild TBI (Concussion)

• Provide comprehensive discharge instructions including warning signs of deterioration, expected symptom course, and monitoring instructions 2, 3
• Recommend gradual return to activity with close monitoring of symptom number and severity 2
• Never prescribe complete rest beyond the first few days, as this may delay recovery 2

Pediatric-Specific Considerations

• Maintain high index of suspicion for inflicted trauma (non-accidental trauma) in children <2 years old 3
• Use age-appropriate ICP thresholds, as physiologic values differ in younger children 3
• Monitor renal function closely with mannitol use in pediatric patients 3

Critical Pitfalls to Avoid

• Never delay neuroimaging in patients with history of lucid interval, even if currently stable 2, 4
• Never use hypotonic fluids that worsen cerebral edema 2
• Never employ prolonged hyperventilation as it causes cerebral ischemia 1, 2, 4
• Never allow hypotension in TBI patients, even with hemorrhagic shock elsewhere 2, 3, 4
• Never assume stability in patients who appear well after initial injury—deterioration can be sudden 2, 4
• Never prescribe complete rest beyond the first few days in mild TBI, as this may delay recovery 2

Destination and Transfer Considerations

• Transport TBI patients to a level I trauma center with round-the-clock neurosurgical expertise whenever possible 6
• Recognize and immediately treat trauma-induced coagulopathy using point-of-care testing 6