Management of Traumatic Brain Injury

Initial Assessment and Classification

The severity of traumatic brain injury (TBI) should be evaluated using the Glasgow Coma Scale (GCS), with severe TBI defined as GCS ≤8, moderate TBI as GCS 9-13, and mild TBI as GCS 14-15 2
Intracranial hypertension should be suspected and treated when major criteria (compressed cisterns, midline shift >5mm, non-evacuated mass lesion) or two minor criteria (GCS motor score ≤4, pupillary asymmetry, abnormal pupillary reactivity, Marshall diffuse injury II) are present 2

ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings, as more than 50% of these patients will develop intracranial hypertension 1
An ICP of 20-40 mmHg is associated with a 3.95 times higher risk of mortality and poor neurological outcome; above 40 mmHg, mortality risk increases 6.9-fold 1
The American College of Surgeons recommends maintaining adequate cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 1
Control ventilation to maintain PaCO2 between 35-40 mmHg during routine management 1
Avoid hypotension, as decreased cerebral perfusion pressure below 60 mmHg can worsen brain edema and secondary injury 1

Osmotherapy with hypertonic saline or mannitol can be used for refractory intracranial hypertension 2, 1
Avoid hypo-osmolar fluids that may worsen cerebral edema 1

Decompressive craniectomy may reduce mortality (26.9% vs 48.9% in medical management) but potentially at the expense of increased severe disability 1
The RESCUE-ICP study showed decompressive craniectomy reduced mortality compared to barbiturate coma but did not improve favorable outcomes at 6 months 1

Oxygenation: Maintain PaO2 between 60-100 mmHg 1
Ventilation: Maintain PaCO2 between 35-40 mmHg (except during temporary hyperventilation for herniation) 1
Coagulation: Maintain platelet count >50,000/mm³ for life-threatening hemorrhage and higher for neurosurgical interventions 1
Hemostasis: Keep PT/aPTT <1.5 times normal control during interventions 1

For patients with both TBI and extracranial injuries causing bleeding, there is a challenging balance between addressing life-threatening hemorrhage and preventing secondary brain injury 3, 4
Avoid "permissive hypotension" strategies in TBI patients as arterial hypotension exacerbates cerebral secondary damage 3, 4

In cases of cerebral herniation, osmotherapy and/or temporary hypocapnia are recommended while awaiting definitive management 1
Point-of-care coagulation tests (TEG, ROTEM) should be utilized when available to guide coagulation management 1