Severe Traumatic Brain Injury (TBI)

• Guideline-supported example content* — Based on Brain Trauma Foundation (BTF) guidelines and published literature. This is not official local protocol. Pending institutional review. Do not substitute for attending guidance, neurosurgery consultation, or current institutional protocols.

• Severe TBI:* GCS ≤ 8 after resuscitation (not explained by sedation or paralytics alone).

Airway

• GCS ≤ 8 → Consider early intubation for airway protection
• Avoid hypoxia: PaO₂ ≥ 60 mmHg (SpO₂ ≥ 90%)
• Document pre-sedation/pre-intubation GCS

Breathing / Oxygenation

• Avoid hypoxia — hypoxia independently worsens TBI outcomes
• Avoid hyperventilation (PaCO₂ < 35 mmHg) unless used for acute herniation (temporary measure only)
• Target PaCO₂ ~35–45 mmHg in stable severe TBI
• For refractory ICP elevation: brief hyperventilation to 30–35 mmHg may be used as bridge to definitive treatment

Circulation

• Avoid hypotension: SBP < 90 mmHg is independently associated with poor outcome
• MAP goal: BTF recommends CPP 60–70 mmHg (CPP = MAP − ICP)
• Aggressive fluid resuscitation to maintain MAP

• Salvageable severe TBI (GCS 3–8 after resuscitation) with:
• Abnormal CT head (hematoma, contusion, swelling, herniation)
• Normal CT but ≥ 2 of: age > 40, SBP < 90, motor posturing

• ICP goal:* < 22 mmHg
• CPP goal:* 60–70 mmHg

Tier 1 (First-line)

• HOB 30° elevation
• Head midline (avoid venous obstruction)
• Avoid hyperthermia (normothermia goal)
• Adequate sedation and analgesia (minimize noxious stimuli)
• Treat seizures (prophylaxis per institutional protocol)
• Maintain normonatremia or mild hypernatremia (avoid hyponatremia)
• Avoid hypovolemia and hypotension

Tier 2

• Hyperosmolar therapy:
• Mannitol (0.25–1 g/kg IV bolus) — monitor serum osmolality
• Hypertonic saline (3% or 23.4%) — monitor sodium levels
• CSF drainage (if ICP monitor is external ventricular drain — EVD)
• Optimize CPP

Tier 3 (Refractory ICP — consult neurosurgery)

• Decompressive craniectomy
• Barbiturate coma (burst suppression)
• Targeted temperature management (therapeutic hypothermia — institutional protocol)

• Standard target:* PaCO₂ 35–40 mmHg
• For acute herniation:* May briefly lower to 30–35 mmHg as bridge to surgical decompression

• Phenytoin / fosphenytoin or levetiracetam for 7 days post-injury in severe TBI
• Reduces early post-traumatic seizures
• No clear benefit beyond 7 days for late seizure prevention

• Coagulopathy — TBI-associated coagulopathy (TACH); may require blood products
• Cerebral salt wasting vs. SIADH — both cause hyponatremia; management differs
• Diabetes insipidus — monitor for in severe/midline TBI
• Herniation syndromes — Cushing's triad (HTN, bradycardia, irregular respirations)
• Neurogenic fever — treat aggressively

• GCS Calculator

• Neuro Assessments / GCS
• Brain Death
• Mechanical Ventilation

• This is guideline-supported example educational content based on Brain Trauma Foundation Guidelines (4th Edition). It is not official local protocol. Verify all management with attending neurosurgery and trauma/critical care team.*