Traumatic Brain Injury Management

Initial Assessment and Severity Stratification

The American College of Surgeons recommends assessing severity immediately using the Glasgow Coma Scale motor response, pupillary size, and pupillary reactivity as these are the strongest predictors of neurological outcome at 6 months 1
Document all three GCS components (eye, verbal, motor) separately rather than as a total score, as recommended by the French Society of Anaesthesia 3
Severe TBI is defined as GCS ≤8, and these patients require immediate tracheal intubation and mechanical ventilation to protect the airway and prevent secondary injury from hypoxia, according to the American Society of Anesthesiologists 1, 2

Patients with GCS ≤8 require immediate tracheal intubation and mechanical ventilation to protect the airway and prevent secondary injury from hypoxia, as recommended by the American Society of Anesthesiologists 2, 4, 5
Also intubate patients with deteriorating conscious level (fall in GCS ≥2 points or motor score ≥1 point), inability to protect airway, or need for transfer to neurosurgical center, according to the American College of Surgeons 2, 5, 1

The cornerstone of TBI management is preventing secondary brain injury by maintaining adequate cerebral perfusion, as recommended by the American Heart Association 2, 5
Secondary injury results from cerebral hypoxia due to reduced oxygen supply (raised intracranial pressure, hypotension, hypoxemia) or increased oxygen demand (hyperthermia, seizures), according to the Brain Injury Association of America 6, 5

Use only isotonic crystalloid (0.9% saline) for fluid resuscitation in TBI patients, as recommended by the American Society of Anesthesiologists 7
Avoid albumin and synthetic colloids, gelatins, Ringer's lactate, and Ringer's acetate, as they are not recommended in early TBI management, according to the European Society of Anaesthesiology 7

For mild TBI (GCS 14-15), perform brain CT scan if ANY high-risk feature is present, such as signs of basilar skull fracture, displaced skull fracture, post-traumatic seizure, focal neurological deficit, coagulation disorders, or current anticoagulant therapy, as recommended by the French Society of Anaesthesia 3, 1

Implement structured neurological monitoring every 15 minutes for the first 2 hours, then hourly for 4-12 hours depending on risk level, as recommended by the American Association of Neurological Surgeons 3
Any decrease of ≥2 points in GCS or new neurological deficits mandates immediate repeat CT scanning, according to the Brain Injury Association of America 3

Resuscitation and stabilization must be underway before transfer—never transfer a hypotensive or hypoxic patient, as recommended by the American College of Surgeons 2, 4, 5
Transfer requirements include designated consultants with responsibility for transfer organization, clinician with appropriate training accompanying the patient, mobile phone for urgent communication, and agreement between referring and receiving facilities on care responsibility, according to the European Society of Anaesthesiology 2, 5, 6

Identify high-risk patients for persistent postconcussive symptoms at initial presentation, including female gender, pre-existing psychiatric history, elevated anxiety scores, loss of consciousness, assault as mechanism, and alcohol intoxication, as recommended by the American Academy of Neurology 8
Screen for specific behavioral symptoms, such as chronic headaches, anxiety, memory problems, difficulty concentrating, sleep difficulties, and abnormal behavior, according to the American Psychological Association 8

Provide structured written and verbal discharge instructions using 6th-7th grade reading level materials with font ≥12 points, including warning signs requiring immediate return, expected symptom trajectory and recovery timeline, and activity restrictions and gradual return-to-work/sport protocols, as recommended by the American College of Emergency Physicians 8, 3
Discharge criteria for mild TBI (GCS 15) with negative CT include no anticoagulation or antiplatelet therapy, no bleeding disorder or previous neurosurgery, reliable follow-up available, and competent caregiver present, according to the American Academy of Family Physicians 3, 7, 1