Acute Management of Traumatic Brain Injury

Abstract

Synopsis Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. As the primary injury cannot be undone, management strategies must therefore focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow (CBF). Cerebral perfusion pressure can be maintained by increasing mean arterial pressure (MAP), decreasing intracranial pressure (ICP), or both. MAP can be increased through a combination of pressors in the euvolemic state, although the ideal fluid in TBI patients is unknown. The goal should be euvolemia and avoidance of hypotension. Elevated intracranial pressure can be treated through an algorithmic approach utilization simple bedside maneuvers, hyperosmolar therapy, cerebral spinal fluid (CSF) drainage as well as pentobarbital coma and decompressive craniectomy in refractory cases. Mass lesions may require operative evacuation depending on size, exam findings, and ICP measurements. Although CPP may not be an ideal surrogate for cerebral blood flow and metabolic delivery, other modalities have not gained widespread use due to paucity of strong data. Other factors that deserve important consideration in the acute management of TBI patients are venous thromboembolism, stress ulcer, and seizure prophylaxis as well as nutritional and metabolic optimization.