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  • GCS < 9 or a motor scale < 5 = severe traumatic brain injury
  • 9 < GCS ≤ 13: “moderate” but beware! Treat like a severe traumatic brain injury until proved otherwise
  • GCS 14–15: minor head injury
  • Beware of “talk-and-deteriorate” patients, whose GCS drops within 48 hours. Usually subdural or extra-dural hematoma


  • C-collar until C-spine “cleared” (see trauma chapter)
  • Tracheal intubation (in-line stabilization, or even fiberoptic)
    • Unclear whether prehospital intubation improves outcome
  • Avoid
    • Decreases in MAP during intubation: use RSI with succinylcholine and ketamine or etomidate. Control MAP strictly. Use ephedrine or norepinephrine if necessary
    • Also avoid large increases in MAP during intubation: topical lidocaine, “soft hands”, IV esmolol if needed


  • Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg


  • Insert A-line
  • Bring MAP > 80 mm Hg with isotonic crystalloids (fluid will not increase ICP in a hypotensive TBI patient)
  • If needed, initiate norepinephrine infusion through a CVL
  • Bring Hb > 8 g/dL
  • If severe hemorrhage due to other lesions, emergent surgical hemostasis might be necessary


  • Sedation-analgesia by midazolam (also prevents initial seizures) and opioids as infusion
  • Emergent CT-scan without contrast; neurosurgery involvement depending on results
  • Fixed dilated pupil (uni- or bilateral) = emergency, incipient herniation
    • Neurosurgical consult STAT
    • Acute hyperventilation to PaCO2 of 25 mm Hg
    • Mannitol 20% 2 mL/kg in 10 minutes IV or 7.5% hypertonic saline (HSS) 125 mL IV en route to CT-scan
    • If the pupils are still fixed and dilated, repeat mannitol 20% 4 mL/kg
  • Patient on warfarin
    • Give prothrombin complex concentrate (PCC 1 mL/kg) or 25 IU/kg factor IX
    • Give Vitamin K 10 mg IV
  • If possible, perform transcranial Doppler (TCD) of MCA
    • Normal values: PI < 1.4 and Vd (diastolic velocity) > 20 cm/s
    • If abnormal, consider increasing MAP and Hb, administering mannitol or HSS

  • Immediately if GCS < 15 or GCS = 15 but associated injuries or patient on warfarin
  • Delayed at 6 hours after the trauma if GCS 15 with initial loss of consciousness
  • Repeat CT-scan if any neurological deterioration
  • Repeat CT-scan after 6 hours if normal initially (in 20% of patients with initially normal CT scans, the repeat scan performed beyond the 6th hour is abnormal)

  • Prevent secondary injury (ischemic, metabolic, excitatory neurotransmitters, reperfusion)
  • Maintain a cerebral perfusion pressure above 60 mm Hg (CPP = MAP − ICP)
  • Maintain normocapnia
  • Maintain normal osmolarity (290–300 mmol/l). Avoid dextrose or hypotonic fluids
  • Seizure prophylaxis: fosphenytoin 13–18 phenytoin equivalents/kg
  • Depending on underlying lesion:
    • Neurosurgery if indicated (extra-dural/subdural hematoma, ventriculostomy, craniectomy if uncontrollable increase in ICP)
    • Factor VIIa if persistent intra-cranial bleeding; controversial, very expensive

  • GCS 15 without warfarin, loss of consciousness or associated injury: no CT-scan, send home with monitoring instruction sheet
  • GCS 15 with ...

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