Management of Brain Trauma from Motor Vehicle Crashes

Initial Assessment and Stabilization

The American College of Surgeons recommends immediate airway control through endotracheal intubation with mechanical ventilation, strict maintenance of systolic blood pressure >110 mmHg using vasopressors without delay, and urgent non-contrast head CT to guide neurosurgical intervention for brain trauma from motor vehicle crashes 1, 2
Establish airway control as the absolute priority through tracheal intubation and mechanical ventilation, beginning from the pre-hospital period, to prevent secondary brain injury in brain-injured patients who cannot protect their airway 1, 2

Confirm correct endotracheal tube placement using end-tidal CO2 monitoring to maintain normal PaCO2 levels, which is critical for preventing secondary brain injury 1
Avoid prophylactic hyperventilation, as hypocapnia causes cerebral vasoconstriction and worsens brain ischemia, and instead maintain PaCO2 within normal range (35-40 mmHg) using continuous end-tidal CO2 monitoring 2, 3

Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological prognosis and increases mortality, and use vasopressors immediately for hypotension rather than waiting for fluid resuscitation 1, 2
Target mean arterial pressure ≥80 mmHg in severe TBI (GCS <8) to ensure adequate cerebral perfusion pressure, and avoid permissive hypotension protocols designed for torso trauma, as these worsen secondary brain injury 1, 3

Obtain non-contrast CT of the brain and cervical spine immediately without delay to detect neurosurgical lesions such as hemorrhage, herniation, and hydrocephalus, and use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone) 1, 2

Surgical evacuation is indicated for acute subdural or epidural hematomas with thickness >5mm and midline shift >5mm, symptomatic intracerebral hematomas with mass effect, hydrocephalus requiring external ventricular drainage, depressed skull fractures, and any cerebellar hematoma >3cm diameter with brainstem compression or hydrocephalus 1, 2, 3

Implement ICP monitoring in severe TBI patients (GCS ≤8) who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy, and target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available 1, 2

Administer propofol by continuous infusion in combination with normocapnia to decrease intracranial pressure, and maintain normothermia using targeted temperature control, as hyperthermia increases complications, unfavorable outcomes, and death 1

Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes, and initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio if needed 1

Implement strategies for detection and prevention of post-traumatic seizures, and maintain biological homeostasis including osmolality, glycemia, and adrenal function, and use mechanical thromboprophylaxis with intermittent pneumatic compression, and delay pharmacological thromboprophylaxis at least 24 hours until bleeding is controlled 1, 3

For patients with GCS 14-15 presenting within 24 hours of motor vehicle crash, obtain non-contrast head CT if any of the following are present: loss of consciousness or posttraumatic amnesia with headache, vomiting, age >60 years, drug/alcohol intoxication, short-term memory deficits, physical trauma above clavicles, posttraumatic seizure, GCS <15, focal neurologic deficit, or coagulopathy, and patients with normal CT and normal neurologic examination can be safely discharged with appropriate discharge instructions 4, 5, 6