Management and Challenges of Severe Traumatic Brain Injury

Abstract

Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro–Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.

Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice

“…Alternative sedative regimens include propofol with morphine or benzodiazepines, although the latter has been associated with an increased risk of delirium [ 263 ]. These sedatives may also decrease systemic blood pressure, resulting reductions in cerebral perfusion pressure, and for this reason ketamine has been proposed as an attractive alternative for maintenance of pharmacologic coma [ 264 ]. Dexmedetomidine has also gained some popularity in the management of refractory intracranial hypertension and shows some promise as an adjunct therapy [ 265 ], although evidence for its routine use in this context is yet to be established.…”

Brain Tissue Damage Induced by Multimodal Neuromonitoring In Situ during MRI after Severe Traumatic Brain Injury: Incidence and Clinical Relevance

“…Continuous cerebral multimodal neuromonitoring has proved to improve both outcome and treatment in critically ill neurosurgical patients, especially after severe traumatic brain injury (sTBI) and subarachnoid hemorrhage (SAH) [ 1 , 2 , 3 , 4 , 5 , 6 ]. Another integral element in the diagnostic and therapeutic management of these patients is advanced neuroimaging.…”

Systematic review and meta-analysis of the effect of nutritional support on the clinical outcome of patients with traumatic brain injury

“…TBI is a common presentation in neurosurgery (1-3) and accounts for 13-21% of all craniocerebral injuries. It is a complex and changeable life-threatening condition with a high fatality rate and poor prognosis that imposes a heavy burden on the patient's family and society (1,4). Patients with TBI experience varying degrees of coma, cannot eat spontaneously, their body functions are affected by trauma and display clear signs of systemic metabolic stress.…”

“…Patients with TBI experience varying degrees of coma, cannot eat spontaneously, their body functions are affected by trauma and display clear signs of systemic metabolic stress. Traumatic brain injury frequently results in nutritional and metabolic disorders as the body's original nutritional reserves are consumed in large quantities, resulting in patients suffering from varying degrees of malnutrition soon after admission (1,5).…”