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  • Primary injury occurs at the moment of trauma and is the result of direct damage to brain tissue. All subsequent preventable brain injuries are termed secondary injuries.

  • Head trauma is associated with cervical spine injury, and stabilization of the spine (eg, cervical collar, log rolling) is maintained until the spine is cleared.

  • Hypoxemia, hypotension, and raised intracranial pressure (ICP) are the leading causes of death in severe traumatic brain injury (TBI) and are related to the severity of the brain injury as well as the systemic complications.

  • Early intubation after moderate to severe TBI is preferred to avoid hypoxemia, aspiration, potential triggering of seizures, and exacerbation of intracranial hypertension that occurs in the crashing, emergently intubated TBI patient.

  • There is likely an age-dependent association between mortality and systolic blood pressure (SBP) after severe TBI. The current Brain Trauma Foundation level III recommendation is to maintain a SBP of at least 100 for patients ages 50 to 69 and above 110 for those older or younger than this age range.

  • The most current BTF guidelines (2016) recommend maintaining CPP between 60 and 70 mm Hg. However, due to the heterogeneity of cerebral injuries and perfusion thresholds in TBI, it has been recognized that a “one size fits all” CPP target for all TBI patients is unlikely to be ideal.

  • Under normal conditions, the CBF is maintained over a MAP range of 50 to 150 mm Hg and is tightly linked to cerebral metabolic rate. After TBI, autoregulation is lost; however, this occurs in a heterogeneous pattern—greater in the areas of injury and less or intact in undamaged areas.

  • TBI is the second highest risk factor for the development of venous thromboembolism (VTE), second only to acute spinal cord injury, and the risk of developing VTE after TBI has been reported up to 54% in the absence of any form of prophylaxis and approximately 20% to 30% in those despite mechanical prophylaxis.

  • As a level IIA recommendation, the Brain Trauma Foundation recommends phenytoin to decrease the incidence of early posttraumatic seizures (PTS) (when overall benefit is thought to outweigh possible complications of treatment) and against prophylactic use of AEDs for prevention of late PTS. There is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy, though recent evidence favors the lower toxicity profile of levetiracetam compared to phenytoin.

  • Optic Nerve Sheath Diameter (ONSD) is limited in the TBI population as it cannot be used in patients with concurrent globe injury, can be less accurate with orbital and facial trauma, and requires patient cooperation to avoid image acquisition errors.


Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide. TBI is caused by blunt force or penetrating injury to the head resulting in brain dysfunction. The severity of TBI may be evident immediately or initially appear to be mild, only to deteriorate later and often rapidly. Symptoms of ...

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