Traumatic Brain Injury Management
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Direct answer
Even one episode of hypotension or hypoxia measurably worsens outcome after severe traumatic brain injury, so management begins in the field: systolic pressure held at 100 mmHg or above (110 for adolescents and the over-seventies), saturation above 90 per cent, and rapid transfer to CT. In the ICU, an intracranial pressure monitor is placed for salvageable severe TBI with a Glasgow Coma Scale of 8 or less and an abnormal CT, pressure is treated above 22 mmHg with cerebral perfusion pressure 60 to 70 mmHg, steroids are prohibited, and tranexamic acid is given within three hours for mild-to-moderate injury.
What you must remember
- Blood pressure floors per Brain Trauma Foundation fourth edition: systolic at least 100 mmHg for ages 50 to 69, at least 110 mmHg for ages 15 to 49 and over 70.
- ICP monitor indications: GCS 8 or less with an abnormal CT (haematoma, contusion, oedema, compressed cisterns), or a normal CT with two or more of age over 40, unilateral or bilateral motor posturing, systolic below 90 mmHg.
- Tranexamic acid per CRASH-3: within three hours of injury in mild-to-moderate TBI (GCS 9 to 15) it reduces head-injury-related death; no benefit in severe injury or after three hours.
- Corticosteroids are contraindicated — the CRASH trial showed increased mortality, and this remains one of the clearest prohibitions in medicine.
- Coagulopathy reversal: warfarin with vitamin K plus four-factor prothrombin complex concentrate (preferred over plasma); direct oral anticoagulants by their specific reversal strategy; antiplatelet agents generally reversed after intracranial bleeding.
- Early nutrition — reaching baseline energy replacement by 48 to 72 hours — and venous thromboembolism prophylaxis from about 48 hours balance catabolism against bleeding risk.
- Decompressive craniectomy is a last-resort tier: DECRA showed early bifrontal decompression for intracranial pressure elevation worsened outcomes; RESCUEicp positioned surgery (unilateral or bifrontal) as an ultimate measure when medical tiers fail.
A night on call, step by step
A 24-year-old motorcyclist arrives with GCS 7, right pupil 5 mm and sluggish, and a systolic of 96. Sequence matters more than speed. Airway with in-line cervical stabilisation and preoxygenation; induction that does not drop pressure — hypotension at intubation is a second injury. A bag of blood or crystalloid running before the induction drug. A single dose of 3 per cent saline for the dilating pupil while CT is prepared, because a unilateral fixed pupil with declining GCS is uncal herniation until an extradural haematoma is excluded. The CT shows a right extradural collection — the operating theatre, not the ICU, is the destination; no monitor or osmotic agent substitutes for evacuation. Postoperatively: ventriculostomy or parenchymal monitor (GCS 8 or less with abnormal CT meets criteria by definition), pressure managed above the 22 mmHg threshold in tiers, propofol-based sedation that can be lifted daily for neurological examination, seizure prophylaxis for seven days, normocapnia, normothermia, sodium 140 to 145 mmol/L. On day four the pressure plateaus at 30 mmHg despite tier two therapy — that is the craniectomy conversation with the family, held before, not after, the pupil dilates.
Where students slip
Three answers fail exams here. "Start steroids to reduce oedema" — contraindicated, CRASH, increased death. "Hyperventilate to PaCO2 30 prophylactically" — cerebral vasoconstriction converts a pressure number into an ischaemic injury; reserve brief hyperventilation for herniation while definitive measures prepare. And the trial mix-up: quoting DECRA and RESCUEicp interchangeably — DECRA was early surgery for raised pressure (worse outcomes), RESCUEicp was end-of-pathway surgery for refractory intracranial hypertension (fewer deaths, more survivors in severe disability). The Indian viva addition: medico-legal documentation — atypical presentations, police intimation for road-traffic injuries, and careful timing records of pupil changes and theatre decisions, because the notes will be read by people other than doctors.
Frequently asked questions
When is intracranial pressure monitoring indicated?
Salvageable severe TBI with GCS 8 or less and an abnormal CT, or a normal CT with two or more of age above 40, motor posturing, or episode of systolic below 90 mmHg.
What are the ICP and CPP targets?
Treat intracranial pressure above 22 mmHg; keep cerebral perfusion pressure between 60 and 70 mmHg.
Which patients receive tranexamic acid after head injury?
Mild-to-moderate TBI (GCS 9 to 15) within three hours of injury per CRASH-3; severe injury and later presentation show no benefit.
How is warfarin-associated intracranial bleeding reversed?
Intravenous vitamin K plus four-factor prothrombin complex concentrate, preferred over fresh frozen plasma for speed and volume.
What did DECRA and RESCUEicp establish?
DECRA: early bifrontal decompression for elevated ICP worsened outcomes; RESCUEicp: decompression as last-line therapy for refractory hypertension lowers mortality at the cost of severe disability in some survivors.
When is antiseizure prophylaxis given after TBI?
For the first seven days in severe injury — no evidence supports longer prophylaxis in the absence of seizures.