What is the immediate management for a patient with a traumatic brain injury?

Immediate Management of Traumatic Brain Injury

For any patient with traumatic brain injury, immediately assess severity using the Glasgow Coma Scale motor response and pupillary examination, secure the airway if GCS ≤8, maintain systolic blood pressure >100 mmHg, obtain urgent CT imaging, and consult neurosurgery for any surgical lesions—these actions directly reduce mortality and prevent devastating secondary brain injury. 1

Initial Assessment and Severity Classification

• Assess severity immediately using the Glasgow Coma Scale (GCS), specifically focusing on the motor response component, along with pupillary size and reactivity—these are the strongest predictors of 6-month neurological outcome. 1, 2

• Document each GCS component separately (Eye-Verbal-Motor) rather than just the total score, as the motor response alone provides critical prognostic information. 1

• Classify severity as: Severe (GCS ≤8), Moderate (GCS 9-13), or Mild (GCS 14-15). 2

• Record the injury mechanism, any loss of consciousness, presence of a lucid interval, and subsequent deterioration—a lucid interval followed by deterioration suggests an expanding epidural hematoma requiring emergency surgery. 3, 4

Airway Management and Respiratory Support

Intubate immediately if GCS ≤8, as early airway control decreases mortality in severe TBI. 2

• Maintain cervical spine protection during intubation until spine injury is excluded. 2

• Target normocapnia with PaCO₂ 35-40 mmHg (or EtCO₂ 30-35 mmHg)—avoid hyperventilation as it causes cerebral vasoconstriction and brain ischemia. 2, 3

• Ensure adequate oxygenation with PaO₂ >90 mmHg, as hypoxia is a major cause of secondary brain injury. 5, 6

• Initiate continuous end-tidal CO₂ monitoring immediately after intubation. 2

Hemodynamic Management

Maintain systolic blood pressure ≥100 mmHg or mean arterial pressure ≥80 mmHg—hypotension dramatically worsens neurological outcomes and must be aggressively corrected. 1, 2

• In polytrauma patients with life-threatening hemorrhage, control bleeding first but never allow prolonged hypotension, as even brief episodes cause irreversible brain damage. 1

• Target cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available. 3, 4

• Avoid "permissive hypotension" strategies entirely in TBI patients—the brain cannot tolerate low blood pressure. 3, 4

Urgent Neuroimaging

Obtain non-contrast head CT immediately without delay in all severe TBI patients (GCS ≤8) and in any patient with a lucid interval, regardless of current neurological status. 1, 2, 4

• Do not wait for hemodynamic stabilization to obtain CT if the patient is salvageable—imaging guides life-saving neurosurgical decisions. 1

• Include cervical spine imaging in the initial CT scan. 2

Neurosurgical Consultation and Intervention

Consult neurosurgery immediately for any of the following surgical lesions identified on CT: 1, 2, 3

• Epidural hematoma with mass effect (classic presentation: lucid interval followed by deterioration)
• Subdural hematoma with midline shift
• Depressed skull fractures
• Open skull fractures with CSF leak or brain tissue exposure
• Any expanding intracranial lesion causing significant mass effect

After controlling life-threatening hemorrhage in polytrauma patients, all salvageable patients with life-threatening brain lesions require urgent neurosurgical intervention. 1

Intracranial Pressure Monitoring and Management

Implement ICP monitoring in severe TBI patients (GCS ≤8) with abnormal CT findings, targeting ICP <20 mmHg. 2, 3

• Consider ICP monitoring in moderate TBI patients with a history of lucid interval or other high-risk features. 3, 4

• Place ICP monitor regardless of the need for emergency extra-cranial surgery in polytrauma patients at risk for intracranial hypertension. 1

Use a tiered approach to manage elevated ICP: 3, 4

First-tier interventions:

• Elevate head of bed to 30 degrees with neutral head and neck position to improve venous drainage 3, 5
• Ensure adequate sedation and analgesia 3
• Maintain normothermia (avoid hyperthermia which worsens outcomes) 5
• Treat seizures immediately if they occur 3

Second-tier interventions for clinical deterioration:

• Osmotic therapy with mannitol 0.25-2 g/kg 3, 4
• Monitor serum osmolarity every 4-6 hours to prevent electrolyte imbalance 5

Prevention of Secondary Brain Injury

Maintain normoglycemia—both hyperglycemia and hypoglycemia worsen brain injury through different mechanisms. 5, 6

• Avoid hypotonic fluids that worsen cerebral edema. 4

• Maintain normal coagulation parameters to prevent expansion of intracranial hemorrhage. 4

• Perform frequent neurological assessments to detect early deterioration. 4

Critical Pitfalls to Avoid

• Never delay CT imaging in patients with a lucid interval who appear stable—deterioration can be sudden and catastrophic. 4

• Never use prolonged hyperventilation as routine therapy—it causes cerebral ischemia. 2, 4

• Never tolerate hypotension in TBI patients, even briefly—secondary brain injury from hypotension is documented in 90% of TBI deaths. 5, 6

• Do not assume mild initial presentation means low risk—patients can deteriorate rapidly. 4

Special Populations

Pediatric patients require the same urgent assessment and management, with these modifications: 2

• Consider lower ICP thresholds (<20 mmHg) in younger children as physiologic ICP values are age-dependent 2
• Maintain high suspicion for non-accidental trauma in children <2 years old 2
• Transfer to a pediatric trauma center with dedicated PICU capabilities, as this improves survival 2