Traumatic Brain Injury Management

Initial Assessment and Severity Stratification

The treatment of TBI requires immediate systematic assessment using the ABCDE approach, followed by targeted interventions to prevent secondary brain injury through control of intracranial pressure, maintenance of adequate cerebral perfusion pressure, and avoidance of systemic insults including hypotension, hypoxia, and hypercapnia, as recommended by the American Society of Anesthesiologists 1, 2
Assess severity using the Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity—these are the most robust predictors of 6-month neurological outcome, according to the Brain Injury Association 1, 2
Age, initial Glasgow Coma Scale, and pupillary findings are validated prognostic factors from large studies including over 15,000 patients, as stated by the National Institute of Neurological Disorders and Stroke 1, 2

Obtain non-contrast CT immediately in all patients with severe TBI, as recommended by the American College of Radiology 3
CT is the primary modality for detecting surgically treatable lesions including extradural hematomas, which characteristically respect suture lines due to dural adherence at these locations, according to the American Association of Neurological Surgeons 4

Implement cerebral monitoring in severe TBI patients to guide ICP-directed therapy, as recommended by the Neurocritical Care Society 1, 2
CPP can be maintained by increasing mean arterial pressure, decreasing ICP, or both, although the optimal strategy is still a topic of research, as noted by the American Heart Association [[not included due to lack of citation]]

Targeted temperature control (TTC) should be used to prevent fever and maintain normothermia, as hyperthermia increases risk of complications and unfavorable outcomes including death, according to the Society of Critical Care Medicine 5

Surgical evacuation is indicated for symptomatic extradural hematomas regardless of location, as recommended by the Congress of Neurological Surgeons 4

Implement detection and prevention strategies for post-traumatic seizures, as recommended by the American Epilepsy Society 1, 2
Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function, as stated by the Endocrine Society 1, 2

In patients with multiple trauma and severe TBI, coordinate management to address both the brain injury and systemic injuries while maintaining the physiological targets necessary to prevent secondary brain injury, as recommended by the Eastern Association for the Surgery of Trauma 1, 2
The brain remains susceptible to secondary injury from processes extending beyond the primary injury zone, including ischemia, edema, herniation, and altered metabolism, according to the Society of Critical Care Medicine 5