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Traumatic brain injury

Key sources
The following summarized guidelines for the evaluation and management of traumatic brain injury are prepared by our editorial team based on guidelines from the Neurocritical Care Society (NCS 2024), the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2023), the French Society of Emergency Medicine (SFMU/SFAR 2022), the American College of Radiology (ACR 2021), the American Academy of Sleep Medicine (AASM 2021), the Eastern Association for the Surgery of Trauma (EAST 2020; 2010), the European Thyroid Association (ETA 2018), the Brain Trauma Foundation (BTF 2017), the European Society of Intensive Care Medicine (ESICM 2017), the Society of Critical Care Medicine (SCCM 2016), the Society of Critical Care Medicine (SCCM/ASPEN 2016), and the American College of Chest Physicians (ACCP 2012).
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Guidelines

1.Diagnostic investigations

Indications for testing: use a screening protocol for the detection of blunt cerebrovascular injury in adult patients with blunt polytrauma.
A
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  • CT

  • MRI

  • CTA

  • Screening for central hypothyroidism

2.Respiratory support

Prophylactic hyperventilation: avoid prolonged prophylactic hyperventilation with PaCO2 =< 25 mmHg.
D

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  • Tracheostomy

3.Medical management

Treatment targets: consider maintaining SBP above the following thresholds to decrease mortality and improve outcomes:
≥ 110 mmHg or above for patients 15 to 49 years of age
≥ 100 mmHg for patients 50 to 69 years of age
> 110 mmHg for patients > 70 years of age
C
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  • Fluid resuscitation

  • Mannitol

  • Sedative agents

  • Corticosteroids

  • Neuromuscular blockade

  • Thromboprophylaxis

  • Seizure prophylaxis

  • Antibiotic prophylaxis

  • Ventilator-associated pneumonia prophylaxis

4.Inpatient care

Intracranial pressure monitoring
Perform ICP monitoring in patients with severe TBI, to reduce in-hospital and 2-week post-injury mortality.
B
Consider using a combination of ICP values and clinical and brain CT findings to guide management in patients with TBI.
C

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  • Jugular bulb monitoring

5.Nonpharmacologic interventions

Nutritional support
As per BTF 2017 guidelines:
Aim to attain basal caloric replacement within 5 days (and at most, within 7 days) of TBI to decrease mortality.
B
Use transgastric jejunal feeding to reduce the incidence of ventilator-associated pneumonia.
B

6.Therapeutic procedures

External ventricular drainage: consider performing CSF drainage to lower ICP in patients with an initial GCS < 6 during the first 12 hours after injury.
C
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  • Induced hypothermia

7.Surgical interventions

Decompressive craniectomy
Do not perform bifrontal decompressive craniectomy as a means to improve outcomes in patients with severe and diffuse TBI (without mass lesions), although recognizing that this procedure is effective to reduce ICP and may decrease ICU length of stay.
D
Perform a large frontotemporoparietal decompressive craniectomy (not less than 12×15 cm or 15 cm diameter) over a small frontotemporoparietal decompressive craniectomy for reduced mortality and improved neurologic outcomes in patients with severe TBI.
B

8.Specific circumstances

Patients with post-traumatic hypersomnia: consider offering armodafinil or modafinil for the treatment of adult patients with hypersomnia secondary to TBI.
C

9.Preventative measures

Helmet use: advise all motorcyclists to wear motorcycle helmets when riding motorcycles to reduce the incidence of head injury and severe head injury after a crash
A
and head injury-related mortality after a crash and to improve overall survival after a crash.
B