Traumatic Brain Injury (TBI) Management

Algorithm Steps

1. ▶

   Start

   Suspected Traumatic Brain Injury

   Head trauma with neurological concern

   1. ●

      Action

      Initial Assessment

      Rapid neurological evaluation

      • Glasgow Coma Scale (GCS)
      • Pupil size and reactivity
      • Focal neurological deficits
      • Mechanism of injury
      • Signs of skull fracture (Battle's sign, raccoon eyes)
      1. ◆

         Decision

         TBI Severity Classification

         Based on GCS score

         • Mild TBI: GCS 13-15
         • Moderate TBI: GCS 9-12
         • Severe TBI: GCS 3-8
         1. ●

            Action

            Mild TBI (GCS 13-15)

            Observation and CT decision

            • Apply Canadian CT Head Rule or NEXUS II
            • CT if high-risk criteria met
            • Observation 4-6 hours if no CT
            • Discharge with head injury instructions
            1. ◆

               Decision

               CT Head Findings

               Assess for surgical lesions

               • Epidural hematoma (EDH)
               • Subdural hematoma (SDH)
               • Intracerebral hemorrhage (ICH)
               • Depressed skull fracture
               • Mass effect / midline shift
               1. ⚠

                  Warning

                  Surgical Lesion Present

                  Emergent neurosurgical consultation

                  • EDH >30mL or SDH >10mm or >5mm midline shift
                  • Open/depressed skull fracture
                  • Posterior fossa mass
                  • Emergent craniotomy/craniectomy
                  1. ●

                     Action

                     ICP Monitoring

                     Indications for monitoring

                     • GCS ≤8 after resuscitation
                     • Abnormal CT (hematoma, contusion, edema)
                     • Or normal CT with ≥2: age >40, posturing, SBP <90
                     • EVD preferred (allows CSF drainage)
                     • Target ICP ≤22 mmHg
                     1. ◆

                        Decision

                        ICP >22 mmHg?

                        Intracranial hypertension

                        1. ●

                           Action

                           Tier 1: Basic Measures

                           First-line ICP management

                           • Head of bed 30°, midline position
                           • Adequate sedation/analgesia
                           • Normothermia (avoid fever)
                           • Normocarbia (PaCO2 35-40)
                           • Treat seizures if present
                           • CSF drainage if EVD in place
                           1. ●

                              Action

                              Tier 2: Osmotic Therapy

                              Refractory ICP elevation

                              • HYPERTONIC SALINE (preferred):
                              • 3% NaCl 250mL bolus, or
                              • 23.4% NaCl 30mL via central line
                              • Target Na 145-155 mEq/L
                              • MANNITOL: 0.25-1 g/kg IV bolus
                              • Avoid if SBP <90 or serum osm >320
                              1. ⚠

                                 Warning

                                 Tier 3: Rescue Therapies

                                 Refractory intracranial hypertension

                                 • Brief hyperventilation (PaCO2 30-35) - temporary
                                 • Barbiturate coma (pentobarbital)
                                 • Decompressive craniectomy
                                 • Therapeutic hypothermia (32-35°C)
                                 • Neurosurgery consultation essential
                                 1. ●

                                    Action

                                    CPP Optimization

                                    Cerebral perfusion pressure management

                                    • CPP = MAP - ICP
                                    • Target CPP 60-70 mmHg
                                    • Use vasopressors if needed (norepinephrine)
                                    • Avoid CPP <50 mmHg (ischemia)
                                    • Avoid CPP >70 mmHg (ARDS risk)
                                    1. ✓

                                       Outcome

                                       Continue ICU Monitoring

                                       Ongoing neuroprotection and rehabilitation planning

         2. ⚠

            Warning

            Severe TBI (GCS ≤8)

            Immediate intervention required

            • INTUBATE - protect airway (GCS ≤8)
            • Avoid hypoxia (SpO2 ≥92%)
            • Avoid hypotension (SBP ≥100 or MAP ≥80)
            • Elevate head of bed 30°
            • Immediate CT head