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Traumatic Brain Injury (TBI) Management

Traumatic Brain Injury (TBI) Management: Suspected Traumatic Brain Injury → Initial Assessment → TBI Severity Classification → Mild TBI (GCS 13-15) → CT...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Suspected Traumatic Brain Injury

    Head trauma with neurological concern

  2. 02Action

    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)
  3. 03Decision

    TBI Severity Classification

    Based on GCS score

    • Mild TBI: GCS 13-15
    • Moderate TBI: GCS 9-12
    • Severe TBI: GCS 3-8
  4. 04Action

    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
  5. 05Decision

    CT Head Findings

    Assess for surgical lesions

    • Epidural hematoma (EDH)
    • Subdural hematoma (SDH)
    • Intracerebral hemorrhage (ICH)
    • Depressed skull fracture
    • Mass effect / midline shift
  6. 06Warning

    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
  7. 07Action

    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
  8. 08Decision

    ICP >22 mmHg?

    Intracranial hypertension

  9. 09Action

    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
  10. 10Action

    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
  11. 11Warning

    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
  12. 12Action

    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)
  13. 13Outcome

    Continue ICU Monitoring

    Ongoing neuroprotection and rehabilitation planning

  14. Path rejoins step 12Shared downstream outcome
  15. Path rejoins step 12Shared downstream outcome
  16. Path rejoins step 12Shared downstream outcome
  17. Path rejoins step 07Shared downstream outcome
  18. 14Warning

    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
  19. Path rejoins step 05Shared downstream outcome

Guideline Source

BTF Guidelines 4th Ed + ACS TBI Best Practices 2024

DOI: 10.1227/NEU.0000000000001432View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Requires ICP monitoring capability for complete implementation
  • Neurosurgery consultation essential for severe TBI
  • Specific dosing may vary by institution
  • Pediatric thresholds differ

Applicable Regions

USEUGlobal
Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Traumatic Brain Injury (TBI) Management?

The Traumatic Brain Injury (TBI) Management is a emergency clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on BTF Guidelines 4th Ed + ACS TBI Best Practices 2024.

What guideline is the Traumatic Brain Injury (TBI) Management based on?

This algorithm is based on BTF Guidelines 4th Ed + ACS TBI Best Practices 2024 (DOI: 10.1227/NEU.0000000000001432).

What are the limitations of the Traumatic Brain Injury (TBI) Management?

Known limitations include: Requires ICP monitoring capability for complete implementation; Neurosurgery consultation essential for severe TBI; Specific dosing may vary by institution; Pediatric thresholds differ. Individual patient factors may require deviation from these recommendations.

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