Prevent secondary brain injury after severe TBI: airway, BP and oxygen targets, CT, seizure and VTE prophylaxis, nutrition, and neurosurgical indications.
At the bedside
Timed steps- 1
Airway and breathing
0-15 minIntubate GCS ≤ 8 with manual in-line stabilisation; avoid hypoxaemia (SpO2 ≥ 94%) and hypotension during induction; PaCO2 35-40 mmHg.
- 2
Blood pressure
SBP ≥ 100 mmHg (age 50-69) or ≥ 110 mmHg (age 15-49 or > 70); avoid hypotonic fluids; vasopressor if needed.
- 3
TXA if within 3 h
≤ 3 hMild-moderate TBI (GCS 9-15) within 3 h: TXA 1 g over 10 min then 1 g over 8 h reduced head-injury death (CRASH-3).
- 4
CT head and neurosurgery
Urgent CT; surgical evacuation for EDH > 30 mL, SDH thickness > 10 mm or midline shift > 5 mm, or deteriorating GCS with mass lesion.
- 5
ICP monitoring
Recommended in salvageable severe TBI with abnormal CT (BTF). Treat ICP > 22 mmHg; CPP 60-70.
- 6
Prophylaxis
Seizures: phenytoin (or levetiracetam) for 7 days for early seizures. VTE: mechanical immediately; LMWH/UFH once haematoma stable (usually 24-72 h, after repeat CT). Stress ulcer prophylaxis if ventilated. Feed by day 5 (ideally earlier) to full calories by day 7.
- 7
Avoid
Steroids, prophylactic hypothermia, prolonged hyperventilation, hyperthermia, hyponatraemia, hyperglycaemia > 180 mg/dL.
Early seizure prophylaxis
Phenytoin
- Dose
- 15-20 mg/kg load at ≤ 50 mg/min, then 100 mg q8h × 7 days
- Worked example
- 70 kg: 1,400 mg (20 mg/kg) in 100 mL NS over ≥ 30 min with ECG monitoring
Alternative prophylaxis
Levetiracetam
- Dose
- 500-1,000 mg q12h × 7 days
- Preparation
- 500-1,000 mg in 100 mL NS over 15 min
BTF found insufficient evidence for superiority over phenytoin; widely used.
Physiological targets in severe TBI
| Parameter | Target |
|---|---|
| SBP | ≥ 100 (50-69 y) / ≥ 110 (15-49 or > 70 y) mmHg |
| CPP | 60-70 mmHg |
| ICP | < 22 mmHg |
| SpO2 / PaO2 | ≥ 94% / > 80 mmHg |
| PaCO2 | 35-40 mmHg (lower only for ICP crisis) |
| Temperature | 36-37.5 °C |
| Glucose | 140-180 mg/dL |
| Sodium | 140-145 mmol/L (higher with osmotherapy) |
| Hb | ≥ 7 g/dL (some target 9) |
Calculators for this topic
References
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Severe TBI initial management
Step 1 of ~6
Intubate with in-line stabilisation; SpO2 ≥ 94%, PaCO2 35-40, SBP ≥ 100-110
Based on Carney N, Totten AM, O'Reilly C, et al; CRASH-3 trial collaborators. Educational use; follow local protocol.
Pathophysiology
Primary injury (contusion, axonal shearing, haematoma) is irreversible; secondary injury (ischaemia, oedema, excitotoxicity, inflammation) evolves over hours to days and is the target of ICU care.
Evidence
- BTF 4th edition: recommendations on BP thresholds, ICP/CPP targets, seizure prophylaxis, nutrition and avoidance of steroids [Carney 2017].
- CRASH-3: TXA within 3 h reduced head-injury-related death in mild-moderate TBI; no benefit in severe TBI with unreactive pupils [CRASH-3 2019].
- CRASH (2004): methylprednisolone increased mortality [CRASH 2004].
Controversies
- Levetiracetam vs phenytoin; transfusion thresholds (HEMOTION 2024 found no significant difference between liberal and restrictive strategies in functional outcome).
🇮🇳 India notes
- Delayed transfers and lack of neurosurgical cover in district hospitals are common; early discussion with a neurosurgical centre and safe transfer (intubated, BP and CO2 controlled) save lives.
- Helmet non-use and drunk driving are major preventable causes.
References
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