Traumatic brain injury management

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• Interpreting traumatic brain injury severity: analysis of the correlation between Glasgow coma scale and abbreviated injury scale
• Association between cranial surgery and mortality among patients with firearm-related traumatic brain injury resulting in subdural hematoma
• Targeting Spermine Oxidase to Mitigate Traumatic Brain Injury Pathology in the Aging Brain
• The Diagnostic and Prognostic Role of Biomarkers in Mild Traumatic Brain Injury: An Umbrella Meta-Analysis
• An Updated and Comprehensive Review Exploring the Gut-Brain Axis in Neurodegenerative Disorders and Neurotraumas: Implications for Therapeutic Strategies
• Kyphoplasty as a Treatment Option for Traumatic Burst Fractures: A Case Series Evaluating Patient Outcomes and Functional Benefits
• Budget Impact Analysis of the Use of Specific Biomarkers GFAP and UCH-L1 in the Management of Mild Traumatic Brain Injury in Spain

Traumatic brain injury (TBI) is one of the main causes of morbidity and mortality worldwide and a frequent cause of care in emergency departments. In its management, there is still no consensus on which factors should condition the use of diagnostic tests to exclude intracranial injuries, although there are some international rules that have been designed for this purpose ^{1) 2)}.

see Traumatic brain injury diagnosis.

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 ³⁾

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

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

Traumatic brain injury management in the intensive care unit.

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

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

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

• Brain Trauma Foundation Guidelines
• ATLS® - Advanced Trauma Life Support
• Neurocritical Care Society Recommendations

Multimodal neuromonitoring for traumatic brain injury management

Traumatic brain injury algorithm

see Traumatic brain injury treatment.

see Traumatic Brain Injury Guidelines.

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 ⁴⁾