What is the recommended management for a patient with traumatic brain injury (TBI)?

Management of Traumatic Brain Injury

Initial Assessment and Severity Classification

Assess TBI severity immediately using the Glasgow Coma Scale (GCS), with severe TBI defined as GCS ≤8, moderate TBI as GCS 9-13, and mild TBI as GCS 14-15. 1 The motor component is the most robust predictor when patients are sedated, as sedation disables eye and verbal response assessment 2.

• Perform brain and cervical CT scan without delay in all severe (GCS ≤8) and moderate (GCS 9-13) TBI patients 2
• For mild TBI (GCS 14-15), obtain CT scan only if high-risk features are present: basilar skull fracture signs (rhinorrhea, otorrhea, hemotympanum, Battle's sign, raccoon eyes), displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulation disorders, or anticoagulant therapy 2, 3
• Use inframillimetric CT sections with double fenestration (brain and bone windows) as the reference standard 2, 1

Prevention of Secondary Brain Injury

Maintain systolic blood pressure ≥110 mmHg and oxygen saturation >90% at all times, as the combination of hypotension and hypoxemia carries a 75% mortality rate. 2, 1, 4

Hemodynamic Management

• Target mean arterial pressure ≥80 mmHg in severe TBI to ensure adequate cerebral perfusion 2
• Avoid any episode of systolic blood pressure <90 mmHg, which significantly increases mortality 2
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment 2
• Vasopressors can be initially infused through peripheral IV access 2

Airway and Ventilation Management

• Intubate and mechanically ventilate all severe TBI patients (GCS ≤8) 2
• Monitor end-tidal CO2 continuously, targeting 30-35 mmHg prior to obtaining arterial blood gases 2, 1
• Avoid hypocapnia, as it induces cerebral vasoconstriction and brain ischemia 2
• Prevent both hypoxemia (SaO2 <90%) and hyperoxia after stabilization 1, 4

Transfer and Specialized Care

Transfer all severe and moderate TBI patients immediately to a specialized center with neurosurgical capabilities and neuro-intensive care, as this significantly improves survival and neurological outcomes. 2, 1, 4

• Pre-hospital management should be performed by a specialized medical team 2
• Even patients not requiring neurosurgical procedures benefit from specialized neuro-intensive care 2

Monitoring Strategies

Neurological Monitoring

• Repeat neurological examinations frequently in moderate TBI: every 15 minutes for the first 2 hours, then hourly for 4-12 hours 2, 3
• Any decrease of ≥2 points in GCS or new neurological deficit mandates immediate repeat CT scan 2, 3

Advanced Monitoring

• Consider transcranial Doppler on arrival to assess cerebral perfusion, with concerning findings being diastolic velocity <20 cm/s and pulsatility index >1.4 2, 1, 4
• Monitor intracranial pressure (ICP) in severe TBI when neurological examination becomes unreliable 2, 4

Management of Intracranial Hypertension

Implement stepwise ICP management starting with basic measures, escalating to invasive interventions only for refractory cases. 1

First-Line Measures

• Elevate head of bed to 20-30 degrees 1
• Restrict free water and avoid excess glucose 1
• Treat hyperthermia aggressively 1
• Maintain adequate sedation with continuous infusions rather than boluses to avoid hemodynamic instability 2
• Control ventilation to maintain PaCO2 30-35 mmHg 2, 1

Second-Line Interventions

• Perform external ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary insults 2, 1
• Administer mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg) 1
• Use hypertonic saline for clinical transtentorial herniation 1

Third-Line Interventions

• Consider decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion 2, 1, 4

Neurosurgical Indications

Immediate neurosurgical intervention is indicated for symptomatic extradural hematoma, significant acute subdural hematoma (thickness >5 mm with midline shift >5 mm), acute hydrocephalus, or displaced open skull fracture. 2

• Removal of brain contusions with mass effect is an option after failure of first-line ICP treatment 2
• Consider CT-angiography for vascular injury if risk factors present: cervical spine fracture, unexplained focal deficit, Horner syndrome, Lefort II/III facial fractures, or basilar skull fractures 2

Positioning and Supportive Care

• Position patients with head elevated 20-30 degrees to facilitate venous return and reduce ICP 1, 5
• Implement venous thromboembolism prophylaxis once hemostasis is secured 6
• Provide stress ulcer prophylaxis 6
• Optimize nutrition and metabolic parameters early 6

Critical Pitfalls to Avoid

Do not administer corticosteroids for TBI management, as they provide no mortality or neurological benefit and may cause harm (RR 1.14,95% CI 0.91-1.42). 1

• Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) for routine clinical decision-making 2, 3
• Do not use hypotensive sedatives as boluses; use continuous infusions instead 2
• Do not delay CT imaging or transfer to definitive care 4, 3
• Do not discharge mild TBI patients on anticoagulation without extended observation or admission 3