Emergency Department Evaluation and Management of Severe Traumatic Brain Injury (Trauma CME)

Table of Contents

 

About This Issue

Severe traumatic brain injury (TBI) is a time-critical emergency, and early decisions made in the ED can influence neurologic recovery and survival. Optimal patient outcomes depend on rapid recognition, close attention to oxygenation and perfusion, timely identification of life-threatening associated injuries, and evidence-based management of elevated intracranial pressure. This issue reviews current best practices for the evaluation and stabilization of patients with severe TBI and addresses ongoing controversies in acute management. In this issue, you will learn:

Key priorities in the initial assessment and resuscitation of patients with severe TBI

How to identify concomitant diagnoses that may worsen outcomes, including nontraumatic precipitating factors

Strategies for maintaining adequate cerebral perfusion and preventing hypotension

Indications for neuroimaging and how imaging findings guide management

Evidence-based approaches to the recognition and tier-based treatment of elevated intracranial pressure

Criteria for neurosurgical consultation and appropriate patient disposition

Current controversies regarding hyperosmolar therapy, tranexamic acid, and other interventions

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of Literature
6. Pathophysiology, Epidemiology, and Etiology
   1. Pathophysiology
      1. Subarachnoid Hemorrhage
      2. Epidural Hematoma
      3. Subdural Hematoma
      4. Contusions
      5. Diffuse Axonal Injury
   2. Epidemiology
   3. Etiology
7. Classification of Traumatic Brain Injury
   1. Clinical Classification
   2. Mechanistic Classification
   3. Radiographic Classification
8. Differential Diagnosis
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
11. Diagnostic Studies
    1. Imaging Studies
       1. Computed Tomography
       2. Ultrasonography
          1. Optic Nerve Sheath Diameter
          2. Optic Disc Elevation
       3. Other Imaging Modalities
    2. Pupillometry
    3. Fluid Biomarkers
       1. Neuron-Specific Enolase
       2. Ubiquitin Carboxy-Terminal Hydrolase L1
       3. S100 Calcium-Binding Protein B
       4. Tau
12. Treatment
    1. Initial Stabilization and Management
    2. Airway Management
       1. Rapid Sequence Intubation
       2. Ventilation Strategies
    3. Hyperosmolar Therapy
    4. Cerebral Perfusion and Hemodynamic Management
    5. Temperature and Metabolic Management
    6. Coagulopathies and Reversal
    7. Prevention of Infectious Complications
    8. Prophylaxis for Deep Vein Thrombosis
    9. Management of Cerebral Venous Sinus Thrombosis
    10. Management of Posttraumatic Seizures
    11. Management of Intracranial Hypertension
        1. Intracranial Pressure Monitoring
        2. Tiered Approach to Management of Elevated Intracranial Pressure
    12. Surgical Management
13. Prognosis and Outcome Prediction
14. Special Circumstances
    1. Repeat Head Injuries
       1. Second Impact Syndrome
       2. Chronic Traumatic Encephalopathy
    2. Combat-Related Traumatic Brain Injury
15. Controversies and Cutting Edge
    1. Multimodal Prognostication
    2. Tranexamic Acid
16. Disposition
17. 5 Things That Will Change Your Practice
18. Risk Management Pitfalls for Emergency Department Management of Severe Traumatic Brain Injury
19. Summary
20. Time and Cost-Effective Strategies
21. Case Conclusions
22. Clinical Pathway for Management of Patients With Suspected Severe Traumatic Brain Injury
23. Tables and Figures
24. References

Abstract

Traumatic brain injury is a significant cause of long-term disability and death worldwide. Recent advances in the acute management of traumatic brain injury have improved outcomes across the full spectrum of disease, including severe injury. Early recognition, optimization of oxygenation and perfusion, and appropriate disposition are essential components of care for patients with severe traumatic brain injury. A systematic history and physical examination are critical to identifying life-threatening injuries and guiding timely interventions, including management of elevated intracranial pressure. This review summarizes current evidence-based recommendations for the emergency department evaluation and management of severe traumatic brain injury, highlights ongoing controversies, and identifies key areas for future research.

Case Presentations

A 70-year-old man with a history of coronary artery disease presents to the ED for headache...

• He reports that the headache began after he sustained a head injury in an assault, but is unable to provide any additional details.
• He says he takes aspirin at home.
• A noncontrast CT of the head shows an acute 0.5-cm right temporal subdural hemorrhage.
• Should you consult neurosurgery for emergent surgical intervention? What medical interventions are indicated? Should repeat imaging be obtained, and if so, when?

A 20-year-old woman with no past medical history presents via EMS after being involved in a motor vehicle crash on a motorcycle…

• EMS reports that she was not wearing a helmet when the crash occurred.
• Her GCS score on arrival at the ED is 6. You immediately place a cervical collar and intubate the patient to stabilize her for imaging.
• A noncontrast CT of the head shows a 0.6-cm right subdural hematoma with 0.7-cm leftward midline shift, subarachnoid hemorrhage in the suprasellar cistern, a 0.2-cm epidural hematoma, and a nondisplaced skull fracture.
• Is additional imaging indicated? What initial interventions should you consider?

A 41-year-old man is brought in by EMS after being hit in the head by a falling metal beam while he was working in a scrap yard…

• EMS reports that the patient was mumbling incoherently and had a GCS score of 12 at the scene.
• On arrival at the ED, his GCS score is 10. He is no longer verbal but does appear to be protecting his airway.
• A noncontrast CT of the head shows a left temporal depressed skull fracture, additional frontal and parietal fractures, left lateral and medial orbital wall fracture, a 0.7-cm subdural hemorrhage, a 0.2-cm epidural hemorrhage, and a 3-mm rightward midline shift of the brain, with a small left parietal intraparenchymal hemorrhage.
• What are your immediate treatment options, and what neurosurgical interventions are indicated?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Management of Patients With Suspected Severe Traumatic Brain Injury

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

5. * Meyfroidt G, Bouzat P, Casaer MP, et al. Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med. 2022;48(6):649-666. (Review) DOI: 10.1007/s00134-022-06702-4

8. * Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15. (Brain Trauma Foundation consensus guidelines) DOI: 10.1227/NEU.0000000000001432

10. * Lulla A, Lumba-Brown A, Totten AM, et al. Prehospital guidelines for the management of traumatic brain injury - 3rd edition. Prehosp Emerg Care. 2023;27(5):507-538. (Brain Trauma Foundation consensus guidelines for prehospital providers) DOI: 10.1080/10903127.2023.2187905

17. * Marehbian J, Muehlschlegel S, Edlow BL, et al. Medical management of the severe traumatic brain injury patient. Neurocrit Care. 2017;27(3):430-446. (Review) DOI: 10.1007/s12028-017-0408-5

25. * Manley GT, Dams-O'Connor K, Alosco ML, et al. A new characterisation of acute traumatic brain injury: the NIH-NINDS TBI classification and nomenclature initiative. Lancet Neurol. 2025;24(6):512-523. (Proposed study framework) DOI: 10.1016/S1474-4422(25)00154-1

35. * Gravesteijn BY, Sewalt CA, Stocchetti N, et al. Prehospital management of traumatic brain injury across europe: a CENTER-TBI study. Prehosp Emerg Care. 2021;25(5):629-643. (Multicenter observational cohort study; 3878 patients) DOI: 10.1080/10903127.2020.1817210

91. * Vrettou CS, Mentzelopoulos SD. Second- and third-tier therapies for severe traumatic brain injury. J Clin Med. 2022;11(16):4790. (Review)

92. * Patel S, Maria-Rios J, Parikh A, et al. Diagnosis and management of elevated intracranial pressure in the emergency department. Int J Emerg Med. 2023;16(1):72. (Review) DOI: 10.1186/s12245-023-00540-x

96. * Muehlschlegel S, Rajajee V, Wartenberg KE, et al. Guidelines for neuroprognostication in critically ill adults with moderate-severe traumatic brain injury. Neurocrit Care. 2024;40(2):448-476. (Clinical practice guideline) DOI: 10.1007/s12028-023-01902-2

97. * Nasrallah F, Bellapart J, Walsham J, et al. PREdiction and Diagnosis using Imaging and Clinical biomarkers Trial in Traumatic Brain Injury (PREDICT-TBI) study protocol: an observational, prospective, multicentre cohort study for the prediction of outcome in moderate-to-severe TBI. BMJ Open. 2023;13(4):e067740. (Observational prospective cohort study protocol) DOI: 10.1136/bmjopen-2022-067740

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Keywords: TBI, severe, traumatic, intracranial, hemorrhage, pressure, ICP, CPP, EDH, SDH, SAH, herniation, hematoma, intraparenchymal, GCS, midline, CT, MRI, coagulopathy, cerebral perfusion, blood pressure, intubation, hyperosmolar