Management of Traumatic Brain Injury

Abstract

Head trauma or traumatic brain injury (TBI) is one of the most serious, life-threatening conditions in trauma victims. Prompt and appropriate therapy is essential to obtain a favorable outcome. The aim of the acute care of patients with brain injury is to optimize cerebral perfusion and oxygenation and to avoid secondary brain injury. Secondary brain injury develops with times and cause further damage to nervous tissues. The common denominators of secondary injury are cerebral hypoxia and ischemia. A systemic approach such as the Advanced Trauma Life Support (ATLS) algorithm has been recommended for managing head injury patients. Quick initial assessment of the patient’s neurologic condition thoroughly is mandatory. There should be attention in evidence of intrathoracic or intraperitoneal hemorrhage in multiple traumatized patients. Optimizing the open airway and adequate ventilation depending on patient’s neurologic condition is first step in emergency therapy. Cerebral perfusion pressure should be maintained between 50 and 70 mmHg. Systemic hypotension is one of the major contributors to poor outcome after head trauma. Careful stabilization of the blood pressure with fluid resuscitation and a continuous infusion of an inotrope or vasopressor may be necessary. Standard monitoring with direct arterial blood pressure monitoring and periodical measurement of arterial blood gases, hematocrit, electrolytes, glucose, and serum osmolarity are important. Brain monitoring as with an electroencephalogram, evoked potentials, jugular venous bulb oxygen saturation (Sjo2), flow velocity measured by transcranial Doppler (TCD), brain tissue oxygenation (btPo2), and ICP monitoring may be used. The reduction of elevated ICP by means of giving barbituates, hyperventilation, diuretics and hyperosmolar fluid therapy, body posture and incremental CSF drainage are critical. Seizure prophylaxis, early enteral feeding, stress ulcer prophylaxis, prevention of hyperglycemic state, fever and prophylaxis against deep venous thrombosis in neurointensive care unit are also important after successful resuscitation of head trauma patients.