Management of Brain Contusion

Immediate Pre-Hospital and Emergency Stabilization

The American College of Surgeons recommends establishing airway control as the absolute priority with tracheal intubation and mechanical ventilation for severe TBI patients, beginning in the pre-hospital period 3
Monitoring end-tidal CO2 continuously is crucial to maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia 3
Confirming correct tracheal tube placement through EtCO2 monitoring is essential 3
Maintaining systolic blood pressure >110 mmHg from first contact is critical, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1
Using vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment is recommended, as these have delayed hemodynamic effects 1

Obtaining non-contrast brain and cervical spine CT immediately without delay is necessary to guide neurosurgical procedures and monitoring techniques 1, 2
Using inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows) is recommended 1

Performing surgical evacuation for symptomatic extradural hematoma, acute subdural hematoma with thickness >5mm and midline shift >5mm, brain contusions with mass effect, acute hydrocephalus requiring drainage, open displaced skull fracture, and closed displaced skull fracture with brain compression is recommended 1, 2, 3

Implementing ICP monitoring in severe TBI to detect intracranial hypertension and guide ICP-directed therapy is essential 1, 2, 3
Maintaining normothermia using targeted temperature control is crucial, as hyperthermia increases complications and unfavorable outcomes including death 1, 2

Implementing detection and prevention strategies for post-traumatic seizures is recommended 2
Maintaining biological homeostasis including osmolarity, glycemia, and adrenal axis function is necessary 2

Never allowing even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors is critical 1
Never using bolus sedation rather than continuous infusions, which causes hemodynamic instability 1
Never delaying transfer to specialized neurosurgical center for "stabilization" at non-neurosurgical facility 1