How should I assess and manage a patient with suspected traumatic brain injury?

Assessment and Management of Traumatic Brain Injury

Immediately assess and stabilize the patient using the ABCDE approach, prioritizing prevention of hypotension (maintain SBP ≥110 mmHg) and hypoxia (maintain SaO₂ >90%), as these secondary insults carry a 75% mortality rate when combined. 1, 2

Initial Stabilization (First Priority)

Prevent secondary brain injury by aggressively correcting systemic insults:

• Maintain systolic blood pressure ≥110 mmHg - any episode of SBP <90 mmHg dramatically increases mortality 1, 2
• Maintain oxygen saturation >90% (ideally >95%) - hypoxemia is associated with poor neurological outcomes at 6 months 1, 2
• Start vasopressors immediately (phenylephrine or norepinephrine) for hypotension rather than waiting for fluid resuscitation; these can be given through peripheral IV access 2
• The combination of hypotension and hypoxemia results in 75% mortality 1

Severity Classification Using Glasgow Coma Scale

Classify TBI severity immediately using GCS: 1

• Severe TBI: GCS ≤8 - requires intubation, mechanical ventilation, and ICU admission
• Moderate TBI: GCS 9-13 - requires close monitoring and urgent CT imaging
• Mild TBI: GCS 14-15 - selective CT imaging based on risk factors

The motor component of GCS is the most reliable predictor of outcome when patients are sedated 2

Neuroimaging Strategy

Obtain immediate brain and cervical CT scan without delay for: 1, 2

• All severe TBI (GCS ≤8)
• All moderate TBI (GCS 9-13)
• Mild TBI (GCS 14-15) with ANY of the following risk factors:
  • Signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, Battle's sign, raccoon eyes)
  • Displaced skull fracture
  • Post-traumatic seizure
  • Focal neurological deficit
  • Coagulation disorders or anticoagulant therapy 1

Use inframillimetric CT sections with double-fenestration (brain and bone windows) as the reference standard 2

Airway Management

Intubate immediately if: 1, 2, 3

• GCS ≤8 (severe TBI)
• Inability to protect airway
• Irregular breathing or absent gag reflex
• Hypoxemia despite supplemental oxygen

After intubation, target end-tidal CO₂ of 30-35 mmHg before obtaining arterial blood gases to guide ventilation 1, 2

Avoid hypocapnia as it causes cerebral vasoconstriction and can lead to brain ischemia 2

Transfer to Specialized Care

Transfer ALL severe and moderate TBI patients immediately to a center with neurosurgical capability and neuro-intensive care unit - this improves survival and neurological outcomes even for patients who don't require surgery 1, 2

Pre-hospital management should be performed by a specialized medical team 1, 2

Neurological Monitoring Protocol

For moderate TBI, perform serial neurological examinations: 1, 2

• Every 15 minutes for the first 2 hours
• Then hourly for the next 4-12 hours

Obtain immediate repeat CT scan if: 1, 2

• GCS decreases by ≥2 points
• New focal neurological deficit appears
• Clinical deterioration occurs

Advanced Monitoring Considerations

Consider transcranial Doppler ultrasonography on arrival - concerning findings include: 1, 2

• Diastolic blood flow velocity <20 cm/s
• Pulsatility index >1.4
• Mean blood flow velocity <28 cm/s

These parameters predict poor outcomes and guide early intervention 1

Management of Intracranial Hypertension

For severe TBI with elevated intracranial pressure: 2

1. Maintain adequate sedation using continuous infusions (not boluses to avoid hemodynamic instability)
2. Control ventilation to keep PaCO₂ at 30-35 mmHg
3. Perform external ventricular drainage for persistent intracranial hypertension unresponsive to sedation
4. Consider decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion

Neurosurgical Consultation Indications

Immediate neurosurgical intervention required for: 2

• Symptomatic extradural hematoma
• Acute subdural hematoma >5 mm thickness with midline shift >5 mm
• Acute hydrocephalus
• Displaced open skull fracture

Critical Pitfalls to Avoid

• Never use serum biomarkers (S100B, NSE, UCH-L1, GFAP) for routine clinical decision-making - they are not recommended for guiding acute management 1, 2
• Never administer hypotensive sedatives as bolus doses - use continuous infusions to prevent hemodynamic instability 2
• Never delay airway protection to complete neurological examination in patients with irregular breathing 4
• Never allow even brief episodes of hypotension or hypoxia - these dramatically worsen outcomes 1, 2