Traumatic brain injury management [Neurosurgery Wiki]

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== Traumatic brain injury management ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1nI_xFaT3LglxDpwutfjuwnnn1JM6tMxj-xcNFA7KC53uvssD1/?limit=15&utm_campaign=pubmed-2&fc=20250401190151}}
----

----
[[Traumatic brain injury]] (TBI) is one of the main causes of [[morbidity]] and [[mortality]] worldwide and a frequent cause of care in [[emergency]] [[department]]s. In its [[management]], there is still no [[consensus]] on which factors should condition the use of diagnostic [[test]]s to exclude intracranial injuries, although there are some international rules that have been designed for this purpose 
((Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, De Maio VJ, et al. The Canadian CT Head
Rule for patients with minor head injury. Lancet. 2001 May;357(9266):1391-6. doi: 10.1016/S0140-
6736(00)04561-X.))
((Lagares A, Ramos A, Arikan F, Del Castillo P, Ehrlich M, Haas T, et al. Variability in the indication of
brain CT scan after mild traumatic brain injury. A transnational survey. Eur J Trauma Emerg Surg. 2023
Jun;49(3):1189-98. doi: 10.1007/S00068-022-01902-5.)).

===== Diagnosis =====

see [[Traumatic brain injury diagnosis]].

===== Protocols =====
There are several protocols for the management of TBI

However, current practice, as presented by literature, shows that each hospital
implements its own approach, and these protocols are not universally integrated into
EHR records

In some centres, the integration of these protocols has been carried
out but not directly into the EHR itself but in an app. This requires duplicate data entry
in the EHR and app, increasing physicians' workload
((Hernández-Sánchez J, Rubio-Mayo P, de la Cruz-Bertolo J, García-Barrio N, Lagares A, Cruz-Bermúdez JL. Modelling and Standardisation of EHR Data for Mild Traumatic Brain Injury Patient Management. Stud Health Technol Inform. 2025 May 15;327:63-67. doi: 10.3233/SHTI250274. PMID: 40380386.))
----

==== 1. Initial Assessment (Prehospital and Emergency Department) ====

**ABC [[Stabilization]]:**
  * **[[Airway]]**: Intubate if GCS ≤ 8.
  * **[[Breathing]]**: Maintain SpO₂ > 94%.
  * **[[Circulation]]**: Avoid hypotension (SBP < 90 mmHg).

**Neurological Evaluation:**
  * **Glasgow Coma Scale (GCS):**
    * Mild: 13–15
    * Moderate: 9–12
    * Severe: ≤ 8
  * [[Pupil reactivity]]
  * Focal neurological signs

**Neuroimaging:**
  * **Non-contrast head CT** if:
    * GCS < 15
    * Focal deficits
    * Suspected skull fracture
    * Seizures, vomiting, anticoagulation, age > 65

==== 2. Emergency Interventions ====

**Neurosurgical Indications:**
  * [[Epidural hematoma]] > 30 cc
  * [[Subdural hematoma]] > 10 mm or midline shift > 5 mm
  * [[Depressed skull fracture]] > 5 mm or open
  * [[Penetrating injury]] with mass effect

**Intracranial Pressure (ICP) Control:**
  * Head elevation to 30º
  * Mannitol (0.25–1 g/kg IV) or hypertonic saline
  * Sedation, mild hyperventilation (PaCO₂ 30–35 mmHg)
  * External ventricular drain (EVD) if hydrocephalus or ICP crisis

==== 3. ICU Management (Moderate to Severe TBI) ====

[[Traumatic brain injury management in the intensive care unit]].



==== 4. Surgical Options ====

  * **Decompressive craniectomy** for refractory ICP > 25 mmHg
  * **Craniotomy** for hematoma evacuation
  * **EVD** for CSF diversion in hydrocephalus or elevated ICP

==== 5. Rehabilitation and Follow-Up ====

**Timing:**
  * Start early rehab as soon as patient is medically stable
  * Multidisciplinary team: physiatry, PT/OT, neuropsychology

**Assessment:**
  * Functional outcome scales (e.g., GOS, GOSE)
  * Neurocognitive evaluation
  * Guidance on return to driving/work

==== 6. Special Considerations ====

  * **Pediatrics**: lower thresholds for ICP crisis, rapid decompensation
  * **Anticoagulated patients**: reverse INR with vitamin K and PCC
  * **Polytrauma**: coordinate with trauma and orthopedic teams

===== References =====

  * [[Brain Trauma Foundation Guidelines]]
  * ATLS® - Advanced Trauma Life Support
  * Neurocritical Care Society Recommendations


===== Multimodal neuromonitoring =====
[[Multimodal neuromonitoring for traumatic brain injury management]]

===== Algorithms =====

[[Traumatic brain injury algorithm]]


===== Treatment =====

see [[Traumatic brain injury treatment]].

===== Guidelines =====

see [[Traumatic Brain Injury Guidelines]].

===== Narrative reviews =====

Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres
((Wiles MD, Braganza M, Edwards H, Krause E, Jackson J, Tait F. Management of traumatic brain injury in the non-neurosurgical intensive care unit: a narrative review of current evidence. Anaesthesia. 2023 Jan 12. doi: 10.1111/anae.15898. Epub ahead of print. PMID: 36633447.))

===== References =====