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

Initial Management of Traumatic Brain Injury

Immediate airway control through endotracheal intubation with mechanical ventilation and aggressive maintenance of systolic blood pressure >110 mmHg using vasopressors without delay are the absolute priorities, followed by urgent non-contrast CT brain imaging to guide neurosurgical intervention. 1

Pre-Hospital and Emergency Stabilization

Airway Management (First Priority)

• Establish airway control immediately through tracheal intubation and mechanical ventilation, beginning in the pre-hospital period. 2
• Pre-hospital tracheal intubation decreases mortality in trauma patients and is critical for preventing hypoxia, which worsens primary brain injury. 2
• Monitor end-tidal CO2 (EtCO2) continuously from the moment of intubation to confirm correct tube placement and maintain PaCO2 within normal range. 2, 1
• Avoid hypocapnia, as it induces cerebral vasoconstriction and risks brain ischemia—this is a common pitfall. 2, 3

Hemodynamic Management (Equally Critical Priority)

• Maintain systolic blood pressure >110 mmHg from first contact with the patient. 2, 1
• Even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome and increases mortality. 2, 1
• Use vasopressors (phenylephrine or norepinephrine) immediately for any hypotension—do not wait for fluid resuscitation or sedation adjustment. 2, 1
• Catecholamines can be initially infused through a peripheral IV catheter if central access is not immediately available. 2

Critical Pitfall to Avoid: Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors—this delays treatment and worsens outcomes. 3

Sedation Strategy

• Use continuous sedation infusions rather than boluses to prevent hemodynamic instability. 2, 1
• Avoid hypotensive sedative agents that could compromise blood pressure. 2
• Propofol administered by continuous infusion can decrease intracranial pressure independently of blood pressure changes. 1

Imaging Strategy

Immediate CT Imaging

• Obtain non-contrast CT of the brain without delay in patients with coma or abnormal neurological examination. 2
• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows). 2, 1
• The initial CT scan guides neurosurgical procedures and monitoring techniques. 2

CT Angiography Indications

• Perform early CT angiography of supra-aortic and intracranial arteries in patients with specific risk factors for traumatic arterial dissection: 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
• Consider extending CT angiography indications to the most severe patients where neurological examination may be limited. 2
• If strong suspicion persists despite normal CT angiography, complete with MR angiography or digital subtraction angiography. 2

Neurosurgical Intervention Criteria

Surgical evacuation is indicated for: 1, 3

• Symptomatic extradural hematoma
• 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 Management

ICP Monitoring

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy. 1
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available. 1

External Ventricular Drainage

• Perform external ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary brain insults. 2
• Drainage of small volumes of CSF can markedly reduce intracranial pressure. 2
• External ventricular drain can be inserted using neuronavigation. 2

Temperature Management

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 3

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 Measures

• Implement detection and prevention strategies for post-traumatic seizures. 1, 3
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1, 3
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes and enhances family communication without reducing survival. 1

Critical Errors to Avoid

• Never use bolus sedation instead of continuous infusions—this causes hemodynamic instability. 1, 3
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility. 1, 3
• Never allow hypocapnia from excessive hyperventilation—this causes cerebral vasoconstriction and brain ischemia. 2, 3
• Never use hypotensive sedative agents for induction. 2