Management of Traumatic Brain Injury and Hemorrhagic Shock

Initial Assessment and Resuscitation

The American College of Surgeons recommends assuming hypotension is due to hemorrhage until proven otherwise in trauma patients, as this is the most common cause, with a mean arterial pressure target of ≥80 mmHg 2
The European Society of Anaesthesiology recommends beginning immediate fluid resuscitation with isotonic crystalloids (0.9% saline) to reverse hypovolemia in patients with traumatic brain injury and hemorrhagic shock 1
The Society of Critical Care Medicine recommends avoiding hypotonic solutions such as Ringer's lactate in patients with head trauma 3
The Brain Trauma Foundation recommends targeting a mean arterial pressure of ≥80 mmHg to maintain cerebral perfusion due to the presence of head injury, with a strength of evidence level I 4
The American College of Emergency Physicians recommends considering vasopressors (metaraminol or norepinephrine) if fluid resuscitation is inadequate to restore blood pressure, with a moderate level of evidence 2

The American Society of Anesthesiologists recommends considering early intubation if GCS is declining or there are signs of increased intracranial pressure, with a high level of evidence 5
The European Society of Anaesthesiology recommends maintaining PaO2 ≥13 kPa and PaCO2 4.5-5.0 kPa if intubated, with a moderate level of evidence 2
The Society of Critical Care Medicine recommends using minimum 5 cmH2O PEEP to prevent atelectasis, with a low level of evidence 2
The American Thoracic Society recommends monitoring end-tidal CO2 continuously if intubated, with a high level of evidence 5

The American College of Surgeons recommends correcting major hemorrhage before considering transfer to definitive care, with a high level of evidence 2
The European Society of Anaesthesiology recommends positioning patient with 20-30° head-up tilt if no spinal injury is suspected, with a moderate level of evidence 2
The Society of Critical Care Medicine recommends considering vasopressors after adequate fluid resuscitation if hypotension persists, with a moderate level of evidence 1
The Brain Trauma Foundation recommends avoiding permissive hypotension strategies due to the presence of traumatic brain injury, with a high level of evidence 2

The American Academy of Neurology recommends performing rapid neurological assessment including GCS and pupillary response, with a high level of evidence 5
The European Society of Anaesthesiology recommends considering short-term hyperventilation (PaCO2 not less than 4 kPa) if signs of increased intracranial pressure develop, with a moderate level of evidence 6
The Society of Critical Care Medicine recommends considering mannitol (0.5 g/kg) or hypertonic saline (2 ml/kg of 3% saline) for signs of increased ICP with impending herniation, with a low level of evidence 6

The American College of Radiology recommends obtaining urgent CT head to evaluate for intracranial injury, with a high level of evidence 5
The Society of Critical Care Medicine recommends considering CT angiography of supra-aortic and intracranial vessels if there are risk factors for vascular injury, with a moderate level of evidence 5
The American Society of Anesthesiologists recommends obtaining complete blood count, coagulation profile, and blood gas analysis, with a moderate level of evidence 2
The European Society of Anaesthesiology recommends considering FAST (Focused Assessment with Sonography for Trauma) to identify sources of bleeding, with a low level of evidence 3

The Brain Trauma Foundation recommends avoiding high-dose glucocorticoids as they increase mortality in severe traumatic brain injury, with a high level of evidence 7
The American College of Surgeons recommends controlling bleeding takes precedence over transfer to another facility, with a high level of evidence 2
The Society of Critical Care Medicine recommends being vigilant for the development of coagulopathy, which is common in patients with combined TBI and hemorrhagic shock, with a moderate level of evidence 3

The American College of Emergency Physicians recommends not delaying fluid resuscitation while waiting for blood products, with a high level of evidence 3
The European Society of Anaesthesiology recommends not transferring a patient who is actively bleeding and hypotensive without stabilization, with a high level of evidence 2
The Society of Critical Care Medicine recommends avoiding rapid correction of blood pressure with bolus doses of sedatives, which may worsen hypotension, with a moderate level of evidence 5