Traumatic Brain Injury

Use the post-resuscitation Glasgow Coma Scale (GCS) to stratify urgency: GCS 13–15 is generally mild TBI, GCS 9–12 moderate TBI, and GCS 8 or less severe TBI. A patient with GCS 9–13 may have a frequency of traumatic CT lesions similar to patients with GCS 9–12 and should not be managed as routine uncomplicated concussion. PubMed+1PubMedEmergency department management of traumatic brain injuriesPubMedHead injury: assessment and early management - NCBI - NIH

For suspected moderate or severe TBI, immediately administer supplemental oxygen regardless of baseline oxygen saturation, obtain continuous pulse oximetry and capnography if ventilated, and actively avoid hypoxia and hypotension. Updated prehospital guidance emphasizes these measures because early secondary insults materially influence outcome. PubMedPubMedGuidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary - PMC

Use hyperventilation only as a temporizing maneuver when clinical herniation is suspected; routine or prolonged hyperventilation can reduce cerebral perfusion and worsen brain hypoxia. Corticosteroids should not be used for TBI management. Wolters KluwerWolters KluwerTrauma : Operative Neurosurgery

Arrange direct transport or urgent transfer to a center with CT, neurosurgical capability, ICP monitoring, and neurocritical care when hospitalization is anticipated for significant TBI. In hospitalized patients, direct transport to a trauma center rather than interfacility transfer has been associated with lower mortality. PubMedPubMedHospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults - PMC

Obtain noncontrast head CT urgently in moderate or severe TBI and in mild TBI when clinical assessment does not support safe deferred imaging. In selected mild or moderate presentations, observation with protective interventions may precede imaging, but deterioration or lack of improvement requires subsequent imaging. Intoxication makes deferred imaging particularly difficult because the neurologic examination is less reliable. PubMedPubMedEmergency department management of traumatic brain injuries

Interpret traumatic CT abnormalities in relation to mass effect and the clinical examination. Epidural, subdural, intraparenchymal, and contusional hemorrhagic lesions can enlarge; diffuse edema, cisternal compression, ventricular effacement, or progressive midline shift should prompt immediate neurosurgical review for invasive monitoring, CSF diversion, evacuation, or decompression as anatomically appropriate. Hemorrhagic progression after TBI is a recognized acute risk. The Lancet+2The LancetCoagulopathy and haemorrhagic progression in traumatic ...Wolters KluwerTrauma : Operative NeurosurgeryPubMedUpdated Review of the Management of and Guidelines for Traumatic Brain Injury

A normal initial CT does not replace observation when symptoms, consciousness, or focal findings worsen. Conversely, normal imaging or imaging not clinically indicated is compatible with use of the diagnostic term concussion interchangeably with mild TBI. ScienceDirect+1ScienceDirectManagement of Concussion and Mild Traumatic Brain InjuryPubMedEmergency department management of traumatic brain injuries

For patients with GCS 8 or less and CT signs of high ICP, use invasive ICP monitoring to guide treatment. An external ventricular drain placed in the frontal horn of a lateral ventricle can measure ICP and permit CSF drainage; intraparenchymal fiber-optic or microstrain devices are alternatives when ventricular placement is difficult. Wolters KluwerWolters KluwerTrauma : Operative Neurosurgery

Prefer ventricular monitoring when CSF diversion is likely to be therapeutic, recognizing that parenchymal monitors measure localized pressure and cannot be recalibrated in vivo. Noninvasive approaches, including transcranial Doppler pulsatility index, optic nerve sheath diameter, near-infrared spectroscopy, and tympanic membrane displacement, should not replace invasive monitoring because accuracy and inter-rater reliability are inadequate. PubMedPubMedTraumatic Brain Injury - StatPearls - NCBI Bookshelf

Maintain an ICP-directed approach that first corrects systemic contributors to secondary injury, including hypoxia and hypotension, then uses ICU interventions and surgery according to the patient’s imaging, monitor data, and neurologic trajectory. Osmotherapy with hypertonic saline or mannitol is used in practice for elevated ICP, but the cited comparative evidence consists of a systematic review of randomized trials rather than a definitive preference for either agent. PubMed+1PubMedGuidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary - PMCWolters KluwerTrauma : Operative Neurosurgery

Reserve decompressive craniectomy for intracranial hypertension refractory to medical management. RESCUEicp-informed guidance indicates lower mortality with craniectomy than medical management alone, but survivors in the surgical group had poorer functional outcomes and more severe disability; decision-making should therefore address survival-disability tradeoffs rather than ICP control alone. PubMedPubMedUpdated Review of the Management of and Guidelines for Traumatic Brain Injury

Use observation with serial neurologic assessment only when the patient has a reliable examination and a pathway for delayed imaging if symptoms worsen or fail to improve. In mild and moderate TBI, this approach is commonly used to avoid immediate imaging in selected patients; lack of improvement or deterioration changes the next step to neuroimaging. PubMedPubMedEmergency department management of traumatic brain injuries

Use concussion and mild TBI interchangeably when neuroimaging is normal or not clinically indicated. Loss of consciousness is not required for post-concussion symptoms or persistent symptom syndromes. ScienceDirect+1ScienceDirectManagement of Concussion and Mild Traumatic Brain InjuryScienceDirectPost-Concussion Syndrome - an overview

At discharge or early follow-up, actively screen for headache, dizziness, visual symptoms, sleep disturbance, cognitive complaints, mood symptoms, post-traumatic stress symptoms, and barriers to return to work. Persistent post-concussion symptoms and PTSD are associated with lower health-related quality of life and lower return-to-work rates than no or mild symptoms. ScienceDirect+1ScienceDirectThe association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injuryScienceDirectPost-Concussion Syndrome - an overview

Do not assume a uniform recovery course. Approximately 55% of concussion patients improve toward recovery within 1–2 weeks, about 30% recover over a longer interval, and approximately 15%–20% develop persistent symptoms requiring longer-term interdisciplinary management. PubMedPubMedRehabilitation and Long-Term Care Needs After Traumatic ...

For moderate or severe TBI, initiate rehabilitation planning during acute hospitalization once physiologic and neurosurgical stability permit. Coordinated long-term follow-up and active early rehabilitation are associated with improved long-term outcomes in pediatric moderate-to-severe TBI, and high-quality inpatient rehabilitation has an important role after more severe injury. PubMedPubMedRehabilitation and Long-Term Care Needs After Traumatic ...

Define the post-acute plan around measurable impairments: mobility and self-care needs, cognition and executive function, communication, swallowing, behavioral dysregulation, mood, sleep, post-traumatic stress symptoms, and return-to-work or school barriers. Post-concussion symptoms and PTSD should be assessed together because their coexistence is associated with worse health-related quality of life. ScienceDirect+1ScienceDirectThe association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injuryPubMedRehabilitation and Long-Term Care Needs After Traumatic ...

Use trauma-center and specialty referral pathways promptly when ongoing neurocritical, neurosurgical, or rehabilitation needs exceed local capacity. Delayed access to definitive care can be harmful in hospitalized TBI, and Level I or II trauma centers provide CT, neurosurgery, ICP monitoring, and related capabilities. PubMedPubMedHospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults - PMC