Traumatic Brain Injury

BACKGROUND

Pathophysiology & Risk

Mechanism of Injury

Primary injury: Direct mechanical damage at the time of the event
Secondary injury: The cascade of cellular and molecular events that occur after the initial injury, leading to further brain damage

Risk factors for TBI include:

Age (young children and older adults are at higher risk)
Participation in high-risk sports
History of previous TBI
Alcohol or drug use

TREATMENTS

Disclaimer: Treatment protocols and medication choices can vary between institutions. If you are practicing or rotating at a specific institution, refer to your institution-specific pathways, order sets, and policies for available products, starting doses, titrations, and safety information.

Initial Management

AIRWAY MANAGEMENT

Prioritize airway protection and adequate ventilation
Intubation may be necessary for patients with decreased level of consciousness or respiratory distress

HEMODYNAMIC SUPPORT

Maintain adequate blood pressure to ensure cerebral perfusion
Use of vasopressors may be necessary in cases of hypotension

Intracranial Pressure (ICP) Management

Osmotic Therapy

MANNITOL

Reduces ICP by drawing fluid from the brain tissue.

Monitor osmolality

HYPERTONIC SALINE

Reduces ICP by drawing fluid from the brain tissue.

Monitor serum sodium

Sedation and Analgesia

PROPOTIONAL AGENTS

Reduce metabolic demand and ICP.
Careful titration is necessary to avoid hypotension.

ANALGESICS

Opioids: Fentanyl or morphine can be used for pain management.
Non-opioid analgesics: Acetaminophen can be used to reduce fever and pain.

Surgical Intervention

DECOMPRESSIVE CRANIECTOMY

Surgical removal of a portion of the skull to allow the brain to swell without increasing ICP.
Reserved for severe cases of refractory ICP elevation.

Other Considerations

SEIZURE PROPHYLAXIS

Anticonvulsant medications may be administered to prevent seizures.
Monitor EEG activity for non-convulsive seizures.

NUTRITIONAL SUPPORT

Early initiation of enteral nutrition to meet metabolic demands.
Monitor electrolytes and adjust accordingly.

TEMPERATURE MANAGEMENT

Fever control to reduce metabolic demand.
Hypothermia may be induced in some cases to reduce brain metabolism and ICP.