Management of Severe Traumatic Brain Injury

Initial Management

The American College of Surgeons recommends immediate control of the airway through endotracheal intubation and mechanical ventilation, strict maintenance of systolic blood pressure >110 mmHg using vasopressors without delay, and urgent acquisition of non-contrast computed tomography of the brain to guide neurosurgical interventions 1, 2
The American Heart Association suggests establishing airway control as an absolute priority through tracheal intubation and mechanical ventilation from the pre-hospital period, with monitoring of end-tidal CO2 to maintain normal PaCO2 levels 3, 1
The Brain Trauma Foundation recommends confirming correct placement of the endotracheal tube through end-tidal CO2 monitoring 1

The American College of Surgeons advises maintaining systolic blood pressure >110 mmHg from the first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological prognosis 1, 2
The American Heart Association suggests using vasopressors (phenylephrine or norepinephrine) immediately in the event of hypotension, rather than waiting for fluid resuscitation or adjustment of sedation 1, 2
The Brain Trauma Foundation recommends avoiding hypotensive sedative agents and using continuous infusions instead of boluses to prevent hemodynamic instability 2

The American College of Radiology recommends obtaining non-contrast computed tomography of the brain and cervical spine immediately without delay to guide neurosurgical procedures and monitoring techniques 1, 2
The American College of Surgeons suggests using inframillimetric reconstructions with a thickness >1mm, visualized with a double window (central nervous system and bone) 1, 2

The Congress of Neurological Surgeons recommends surgical evacuation in the following situations: hematoma, subdural hematoma, cerebral contusion, hydrocephalus, and skull fracture 1, 2

The Brain Trauma Foundation advises implementing intracranial pressure monitoring in severe traumatic brain injury to detect intracranial hypertension and guide pressure-directed therapy 1
The American Heart Association recommends maintaining normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes, including death 1, 2

The Society of Critical Care Medicine suggests that propofol administered by infusion or slow bolus in combination with hypocapnia is capable of decreasing intracranial pressure independently of changes in blood pressure 1

The American College of Surgeons recommends implementing strategies for detection and prevention of post-traumatic seizures 3, 1
The American Heart Association advises maintaining biological homeostasis, including osmolality, glycemia, and adrenal function 3, 1

The American Thoracic Society suggests that increasing positive end-expiratory pressure (PEEP) from 0 to 5, 6-10, and 11-15 cm H₂O is associated with a decrease in intracranial pressure and improvement in cerebral perfusion pressure 1

The American College of Surgeons warns against using sedation in bolus instead of continuous infusions, which causes hemodynamic instability 1, 2
The Brain Trauma Foundation advises against delaying transfer to a specialized neurosurgical center for "stabilization" in a facility without neurosurgery 1, 2

The American College of Surgeons recommends implementing ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy 4
Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available, adjusting based on individual autoregulation status, as recommended by the World Journal of Emergency Surgery 5
Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension, as suggested by the World Journal of Emergency Surgery and Anaesthesia 5, 4

Maintain platelet count >100,000/mm³ in TBI patients, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes, according to the World Journal of Emergency Surgery 6
Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio, then modify based on laboratory values, as recommended by the World Journal of Emergency Surgery 6, 5

Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes, reduces length of stay, and enhances communication with family members without reducing survival, as suggested by the World Journal of Emergency Surgery 7