What is the plan of care for a patient with traumatic brain injury?

Traumatic Brain Injury Plan of Care

The plan of care for traumatic brain injury centers on preventing secondary brain injury through aggressive maintenance of cerebral perfusion, systematic severity assessment using Glasgow Coma Scale and pupillary examination, early airway protection for severe cases (GCS ≤8), and structured monitoring with clear escalation protocols. 1

Initial Assessment and Severity Stratification

Assess severity immediately using the Glasgow Coma Scale motor response, pupillary size, and pupillary reactivity as these are the strongest predictors of neurological outcome at 6 months. 1 Document all three GCS components (eye, verbal, motor) separately rather than as a total score. 2

Severity Classification:

• Mild TBI: GCS 14-15 2
• Moderate TBI: GCS 9-13 3
• Severe TBI: GCS ≤8 1

Age, initial GCS, and pupillary findings remain the key prognostic factors even in contemporary studies. 1

Airway Management and Intubation Criteria

Patients with GCS ≤8 require immediate tracheal intubation and mechanical ventilation to protect the airway and prevent secondary injury from hypoxia. 1

Also intubate patients with:

• Deteriorating conscious level (fall in GCS ≥2 points or motor score ≥1 point) 1
• Inability to protect airway 1
• Need for transfer to neurosurgical center 1

Anterior circulation stroke patients for thrombectomy rarely need airway intervention and should be transferred without delay. 1

Prevention of Secondary Brain Injury

The cornerstone of TBI management is preventing secondary brain injury by maintaining adequate cerebral perfusion. 1 Secondary injury results from cerebral hypoxia due to reduced oxygen supply (raised intracranial pressure, hypotension, hypoxemia) or increased oxygen demand (hyperthermia, seizures). 1

Critical Physiologic Targets:

Blood Pressure Management:

• Maintain systolic blood pressure >110 mmHg at minimum 2
• Avoid hypotension aggressively—the combination of hypotension and hypoxemia carries 75% mortality 2
• For severe TBI during transfer, maintain mean arterial pressure adequate for cerebral perfusion 1

Oxygenation:

• Maintain oxygen saturation >90% 2
• Avoid both hypoxemia and hyperoxemia 4

Ventilation (for intubated patients):

• Target normocapnia (PaCO2 35-45 mmHg) 5
• Normocapnia at hospital admission is strongly associated with reduced mortality 5
• Only 33% of prehospital intubated patients achieve normocapnia, highlighting the difficulty of this target 5
• End-tidal CO2 correlates poorly with arterial CO2, so arterial blood gas monitoring is essential 5

Common pitfall: Permissive hypotension during resuscitation of polytrauma patients should only be considered in exceptional circumstances when TBI is present, and requires escalation to trauma network discussion. 1 Hypotension must be assumed due to hemorrhage and controlled before transfer. 1

Fluid Resuscitation

Use only isotonic crystalloid (0.9% saline) for fluid resuscitation in TBI patients. 1 This is the only commonly available isotonic solution when real osmolality (mosmol/kg) rather than theoretical osmolality is measured. 1

Avoid:

• Albumin and synthetic colloids (not recommended in early TBI management) 1
• Gelatins, Ringer's lactate, and Ringer's acetate (hypotonic and may worsen cerebral edema) 1

Correct hypovolemia before transfer, as hypovolemic brain-injured patients tolerate transfer poorly. 1

Imaging Strategy

For mild TBI (GCS 14-15), perform brain CT scan if ANY high-risk feature is present: 2

• Signs of basilar skull fracture
• Displaced skull fracture
• Post-traumatic seizure
• Focal neurological deficit
• Coagulation disorders
• Current anticoagulant therapy

This represents a Grade 1+ (strong) recommendation from the French Society of Anaesthesia. 2

Monitoring and Observation Protocols

For patients not requiring immediate surgery, implement structured neurological monitoring: 2

• Every 15 minutes for first 2 hours
• Then hourly for 4-12 hours depending on risk level

Any decrease of ≥2 points in GCS or new neurological deficits mandates immediate repeat CT scanning. 2

Monitoring during transport must adhere to published guidelines, with continuous assessment of vital signs and neurological status. 1

Transfer Considerations

Resuscitation and stabilization must be underway before transfer—never transfer a hypotensive or hypoxic patient. 1 Transfer of actively bleeding hypotensive patients should not be considered; bleeding must be controlled first. 1

Transfer requirements:

• Designated consultants with responsibility for transfer organization 1
• Clinician with appropriate training accompanying the patient 1
• Mobile phone for urgent communication 1
• Agreement between referring and receiving facilities on care responsibility 1

Emergency neurosurgical admission should never be delayed, and lack of critical care beds should not be a reason for refusing admission for patients requiring urgent surgery. 1

Behavioral and Postconcussive Syndrome Management

Identify high-risk patients for persistent postconcussive symptoms at initial presentation: 6

• Female gender
• Pre-existing psychiatric history
• Elevated anxiety scores (strongest predictor at 3 months)
• Loss of consciousness
• Assault as mechanism
• Alcohol intoxication
• No recall of discharge information

Screen for specific behavioral symptoms: chronic headaches, anxiety, memory problems, difficulty concentrating, sleep difficulties, abnormal behavior. 6

Mandate 2-3 days off work or school for patients with postconcussive symptoms, with strict avoidance of strenuous mental or physical activity until symptom-free. 6

Discharge Planning and Follow-up

Provide structured written and verbal discharge instructions using 6th-7th grade reading level materials with font ≥12 points: 6, 2

• Warning signs requiring immediate return: repeated vomiting, worsening headache, confusion, abnormal behavior, increased sleepiness, seizures 6
• Expected symptom trajectory and recovery timeline 2
• Activity restrictions and gradual return-to-work/sport protocols 2

Discharge criteria for mild TBI (GCS 15) with negative CT: 2

• No anticoagulation or antiplatelet therapy
• No bleeding disorder or previous neurosurgery
• Reliable follow-up available
• Competent caregiver present

Refer to TBI specialist when symptoms persist beyond 3 weeks, or earlier if planning return to sports or if risk factors present. 6 Early intervention improves outcomes; do not delay specialist referral. 6

Common Pitfalls to Avoid

Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) for routine clinical decision-making (Grade 2- recommendation). 2

Do not perform routine repeat CT in mild TBI patients with negative initial CT and stable examination. 2

Do not discharge patients on anticoagulation without extended observation or admission. 2

Do not rely on home observation protocols for patients with negative CT or low-risk features—this is not evidence-based. 6

Do not dismiss anxiety symptoms—they are the strongest predictor of persistent postconcussive syndrome. 6

Long-term Considerations

Recognize TBI as a chronic disease process, not merely an acute event. 7 TBI increases long-term mortality, reduces life expectancy, and is associated with increased incidences of seizures, sleep disorders, neurodegenerative diseases, neuroendocrine dysregulation, psychiatric diseases, and systemic metabolic dysregulation that may persist for months to years. 7 Approximately 18.7% of mild TBI patients report 3 or more postconcussive symptoms, with fatigue and forgetfulness being most common. 6