What is the recommended acute management for an adult with moderate to severe traumatic brain injury, including airway, breathing, circulation, cervical spine protection, Glasgow Coma Scale assessment, indications for intubation, non‑contrast head CT criteria, surgical evacuation of intracranial hemorrhage, intracranial pressure control measures, seizure prophylaxis, deep‑venous thrombosis prophylaxis, and hemodynamic targets?

Management of Traumatic Brain Injury

Initial Assessment and Severity Evaluation

Assess severity using the Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity as your primary clinical tools. 1

• The motor response remains the most robust predictor of severity even when sedation or intubation prevents assessment of eye and verbal components 1
• Pupillary size and reactivity are validated as key determinants of 6-month neurological outcome in large studies including over 15,000 patients 1
• Repeat neurological examination every 15 minutes for the first 2 hours, then hourly for at least 12 hours to detect secondary deterioration 1
• Any decrease of 2 or more points in Glasgow Coma Scale score mandates immediate repeat CT imaging 1, 2

Airway Management with Cervical Spine Protection

Perform tracheal intubation with inline cervical spine stabilization rather than rigid collar immobilization during the procedure. 1

• Pre-hospital tracheal intubation decreases mortality in severe TBI patients 1
• Videolaryngoscopy is now preferred over awake intubation given time-critical nature of interventions and frequent patient non-compliance from intoxication or brain injury 1
• The risk of secondary spinal cord injury from airway management is extremely low (0.34% neurological complication rate in 1177 patients requiring intubation) 1
• Avoid hypotensive induction agents; use continuous sedation rather than boluses to prevent blood pressure drops 1

Ventilation Targets

Maintain end-tidal CO2 monitoring continuously and target PaCO2 between 30-39 mmHg (or EtCO2 equivalent). 1, 3

• Hypocapnia induces cerebral vasoconstriction and increases risk of brain ischemia 1
• Patients achieving PaCO2 30-39 mmHg have mortality of 21.2% compared to 33.7% for those outside this range 3
• Monitor EtCO2 from the pre-hospital phase through emergency department to confirm proper tube placement and maintain appropriate ventilation 1

Hemodynamic Targets

Maintain systolic blood pressure >110 mmHg at all times; even a single episode of hypotension worsens outcome. 1

• Systolic blood pressure <90 mmHg is associated with significantly worse neurological outcome 1
• Mortality increases markedly when systolic blood pressure drops below 110 mmHg 1
• Use vasopressors (phenylephrine or norepinephrine) immediately to correct hypotension rather than waiting for fluid resuscitation or sedation adjustment 1
• Catecholamines can be initially infused through peripheral IV while central access is obtained 1

Imaging

Perform non-contrast head CT and cervical spine CT without delay in all severe TBI patients. 1

• Use inframillimetric sections reconstructed with thickness >1mm, visualized with both CNS and bone windows 1
• The initial CT guides neurosurgical procedures and monitoring techniques 1

Add CT angiography of supra-aortic and intracranial vessels if any of these risk factors are present: 1

• 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

Neurosurgical Intervention

Consult neurosurgery immediately, as 8-40% of patients with GCS ≤8 require surgical intervention. 2

• External ventricular drainage should be performed for persistent intracranial hypertension despite sedation and correction of secondary brain insults 1
• Small volume CSF drainage can markedly reduce intracranial pressure 1

Seizure Prophylaxis

The guidelines reviewed do not provide specific recommendations for routine seizure prophylaxis timing or agents in the acute phase. 1

• Detection and prevention of post-traumatic seizures was identified as a key management topic requiring attention 1
• Patients with severe TBI have 11.9% seizure risk in the first year, requiring vigilant monitoring 4

Venous Thromboembolism Prophylaxis

Initiate pharmacological VTE prophylaxis (low molecular weight heparin) within 24 hours of injury in severe TBI patients. 5

• Early VTE chemoprophylaxis (mean time 24 hours) does not increase risk of intracranial hemorrhage progression (16% with prophylaxis vs 17% without, RR=0.91) 5
• DVT/PE incidence was 12% with early prophylaxis versus 17% without (RR=0.73) 5
• Modern mechanical and pharmacological prophylaxis achieves proximal leg DVT rate of only 3%, though overall VTE rate remains 11% 6

Transfer to Specialized Center

Transfer all severe TBI patients to a specialized neuro-intensive care unit or neurosurgical center. 1

• Management in specialized neuro-intensive care is associated with improved neurological outcome and lower mortality even for patients not requiring neurosurgical procedures 1
• This benefit persists after adjusting for Glasgow Coma Scale, age, and hypotension on arrival 1

Critical Pitfall to Avoid

Do not make irreversible treatment limitation decisions before 72 hours unless brain death criteria are met. 2

• Failure to show neurological improvement within 72 hours is a negative prognostic factor, but decisions should not be premature 2
• Do not delay correction of hypotension and hypoxemia while awaiting imaging or neurosurgical consultation 2