Skip to main content
SpringerLink
Log in

Management of Moderate and Severe TBI

  • Chapter
  • First Online:
Traumatic Brain Injury

  • 2456 Accesses

Abstract

The management of moderate and severe traumatic brain injury (TBI) is a complex and evolving practice in the acute neurosciences. The management, beginning in the prehospital environment to tertiary definitive medical and surgical management of TBI, is discussed. Clinical syndromes and radiographic examples of brain injury are presented, along with a current review of the literature in the early critical care phase of moderate and severe TBI management. We discuss an algorithm for managing the challenging patient and discuss areas of needed future research.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 149.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250–8.

    Article  PubMed  Google Scholar 

  2. Giza C, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2250–7.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Physician. 2012;58:257–67, e128–40.

    PubMed  PubMed Central  Google Scholar 

  4. Geocadin R, Bhardwaj A, Mirski M, et al. Traumatic brain injury. Totowa: Humana Press; 2004.

    Google Scholar 

  5. Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury. J Neurosurg. 2009;110:1242–6.

    Article  PubMed  Google Scholar 

  6. Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95:560–8.

    Article  CAS  PubMed  Google Scholar 

  7. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–4.

    Article  CAS  PubMed  Google Scholar 

  8. American College of Surgeons. Advanced trauma life support, program for doctors. 9th ed. Chicago; 2012.

    Google Scholar 

  9. Surgical management of penetrating Brain injury. J Trauma. 2001:S16–25.

    Google Scholar 

  10. RC CRASH Trial Collaborators, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336:425–9.

    Article  Google Scholar 

  11. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, et al. Guidelines for the management of severe traumatic brain injury: III. Prophylactic Hypotheramia. J Neurotrauma. 2007;24(suppl 1):S21–5.

    Google Scholar 

  12. Marion DW, Penrod LE, Kelsey SF, Obrist WD, Kochanek PM, Palmer AM, et al. Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med. 1997;336:540–6.

    Article  CAS  PubMed  Google Scholar 

  13. Davis DP, Meade W, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury. J Neurotrauma. 2009;26:2217–23.

    Article  PubMed  Google Scholar 

  14. Bell RS, Vo AH, Neal CJ, Tigno J, Roberts R, Mossop C, et al. Military traumatic brain and spinal column injury: a 5 year study of the impact blast and other military grade weaponry on the central nervous system. J Trauma. 2009;66(4 suppl):S104–11.

    Article  PubMed  Google Scholar 

  15. Armonda RA, Bell RS, Vo AH, DeGraba TJ, Crandall B, Ecklund J, et al. Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurgery. 2006;59:1215–25.

    Article  PubMed  Google Scholar 

  16. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. Lippincott Williams & Wilkings: Baltimore; 2007.

    Google Scholar 

  17. Blumenfeld H. Neuroanatomy through clinical cases. Sunderland: Sinauer Associates; 2002.

    Google Scholar 

  18. Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, et al. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir. 2008;150:1241–7.

    Article  CAS  PubMed  Google Scholar 

  19. Vilela MD. Delayed paradoxical herniation after a decompressive craniectomy: case report. Surg Neurol. 2008;69:293–6.

    Article  PubMed  Google Scholar 

  20. Muehlschlegel S, Voetsch B, Sorond FA. Emergent epidural blood patch: lifesaving treatment of paradoxical herniation. Arch Neurol. 2009;66:670–1.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of traumatic parenchymal lesions. Neurosurgery. 2006;58(3 suppl):S25–46.

    PubMed  Google Scholar 

  22. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28:547–53.

    Article  PubMed  Google Scholar 

  23. Narayan RK, Maas AI, Marshall LT, Servadei F, Skolnick BE, Tillinger MN; et al. Traumatic ICH Study Group. Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery. 2008;62:776–786.

    Google Scholar 

  24. Ling GS, Marshall SA. Management of traumatic brain injury in the intensive care unit. Neurol Clin. 2008;26:409–26.

    Article  PubMed  Google Scholar 

  25. The Brain Trauma Foundation. http://braintrauma.org.

  26. Warner KJ, Cuschieri J, Compass MK, Jurkovich GJ, Bulger EM. Emergency department ventilation effects outcome in severe traumatic brain injury. J Trauma. 2008;64:341–7.

    Article  PubMed  Google Scholar 

  27. McHugh GS, Engel DC, Butcher I, Steyerberg EW, Lu J, Mushkudiani N, et al. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007;24:287–93.

    Article  PubMed  Google Scholar 

  28. Stiver SI, Manley GT. Prehospital management of traumatic brain injury. Neurosurg Focus. 2008;33(3 suppl):S228–40.

    Google Scholar 

  29. Chesnut RM, Marshall LF, Klaubeer MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;24:216–22.

    Article  Google Scholar 

  30. Schreiber MA, Aoki N, Scott BG, Beck JR. Determinants of mortality in patients with severe blunt head injury. Arch Surg. 2002;137:285–90.

    Article  PubMed  Google Scholar 

  31. Chesnut RM, Marshall LF. Management of severe head injury. 3rd ed. New York: Raven Press; 1993.

    Google Scholar 

  32. Barton CW, Hemphill JC, Morabito D, Manley G. A novel method of evaluating the impact of secondary brain insults on functional outcomes in traumatic brain-injured patients. Acad Emerg Med. 2005;12:1–6.

    Article  PubMed  Google Scholar 

  33. Jenkins LW, Moszynshi K, Lyeth BG, Lewelt W, DeWitt DS, Allen A, et al. Increased vulnerability of the mildly traumatized rat brain to cerebral ischemia: the use of controlled secondary ischemia as a research tool to identify common or different mechanisms contributing to mechanical and ischemic brain injury. Brain Res. 1989;477:211–24.

    Article  CAS  PubMed  Google Scholar 

  34. Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, et al. Causes of death in U.S. special operations forces in the global war on terrorism. Ann Surg. 2007;245:986–91.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62:112–9.

    Article  PubMed  Google Scholar 

  36. SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, George Institute for International Health, Myburgh J, Cooper DJ, Finfer S, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. NEJM. 2007;357:874–84.

    Article  Google Scholar 

  37. Clifton GL, Miller ER, Choi SC, Levin HS. Fluid thresholds and outcome from severe brain injury. Crit Care Med. 2002;30:739–45.

    Article  PubMed  Google Scholar 

  38. Raslan A, Bhardwaj A. Medical management of cerebral edema. Neurosurg Focus. 2007;22:E12.

    Article  PubMed  Google Scholar 

  39. Ehtisham A, Taylor S, Bayless L, Klein MW, Janzen JM. Placement of external ventricular drains and intracranial pressure monitors by neurointensivists. Neurocrit Care. 2009;10:241–7.

    Article  PubMed  Google Scholar 

  40. Harris CH, Smith RS, Helmer SD. Placement of intracranial pressure monitors by non-neurosurgeons. Am Surg. 2002;68:787–90.

    PubMed  Google Scholar 

  41. Marshall LF, Smith RW, Rauscher LA, Shapiro HM. Mannitol dose requirements in brain-injured patients. J Neurosurg. 1978;48:169–72.

    Article  CAS  PubMed  Google Scholar 

  42. Stein DG, Wright DW, Kellermann AL. Does progesterone have neuroprotective properties? Ann Emerg Med. 2008;51:164–72.

    Article  PubMed  Google Scholar 

  43. Diringer MN, Zazulia AR. Osmotic therapy: fact and fiction. Neurocrit Care. 2004;1:219–33.

    Article  CAS  PubMed  Google Scholar 

  44. Koenig MA, Bryan M, Lewin JL III, Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with hypertonic saline. Neurology. 2008;70:1023–9.

    Article  CAS  PubMed  Google Scholar 

  45. Ware ML, Nemani VM, Meeker M, Lee C, Morabito DJ, Manley GT. Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury: a preliminary study. Neurosurgery. 2005;57:727–36.

    Article  PubMed  Google Scholar 

  46. Rockswold GL, Solid CA, Paredes-Andrade E, Rockswold SB, Jancik JT, Quickel RR. Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen. Neurosurgery. 2009;65:1035–41.

    Article  PubMed  Google Scholar 

  47. US Army Institute of Surgical Research. Joint Trauma System: clinical practice guidelines. 2011. www.usaisr.amedd.army.mil/cpgs.html.

  48. Szaflarski JP, Sangha KS, Shutter LA. Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care. 2010;12(2):165–72.

    Article  CAS  PubMed  Google Scholar 

  49. Kelly DF, Goodale DB, Williams J, Herr DL, Chappell ET, Rosner MJ, et al. Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg. 1999;90:1042–52.

    Article  CAS  PubMed  Google Scholar 

  50. Marion DW, Firlik A, McLaughlin MR. Hyperventilation therapy for severe traumatic brain injury. New Horiz. 1995;3:439–47.

    CAS  PubMed  Google Scholar 

  51. Jia X. Improving neurological outcomes post-cardiac arrest in a rat model: immediate hypothermia and quantitative EEG monitoring. Resuscitation. 2008;90:1042–52.

    Google Scholar 

  52. Qui WS, Liu WG, Shen H, Wang WM, Hang ZL, Zhang Y, et al. Therapeutic effect of mild hypothermia on severe traumatic head injury. Chin J Traumatol. 2005;8:27–32.

    Google Scholar 

  53. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7:728–41.

    Article  PubMed  Google Scholar 

  54. Mossad EB, Machado S, Apostolakis J. Bleeding following deep hypothermia and circulatory arrest in children. Semin Cardiothorac Vasc Anesth. 2007;11:34–46.

    Article  PubMed  Google Scholar 

  55. Valeri CR, Feingold H, Cassidy G, Ragno G, Khuri S, Altschule MD. Hypothermia-induced reversible platelet dysfunction. Ann Surg. 1987;205:175–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Michelson AD, MacGregor H, Barnard MR, Kestin AS, Rohrer MJ, Valeri CR. Reversible inhibition of human platelet activation by hypothermia in vivo and in vitro. Thromb Haemost. 1994;71:633–40.

    Article  CAS  PubMed  Google Scholar 

  57. Watts DD, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function and fibrinolytic activity. J Trauma. 1998;44:846–54.

    Article  CAS  PubMed  Google Scholar 

  58. Polderman KH. Application of therapeutic hypothermia in the intensive care unit. Opportunities and pitfalls of a promising treatment modality-part 2: practical aspects and side effects. Intensive Care Med. 2004;30(5):757–69.

    Article  PubMed  Google Scholar 

  59. Qureshi AI. SJI. More evidence supporting a brain code protocol for reversal of transtentorial herniation. Neurology. 2008;70:990–1.

    Article  PubMed  Google Scholar 

  60. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364:1493–502.

    Article  CAS  PubMed  Google Scholar 

  61. Hutchinson PI, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. New Engl J Med. 2016;375:1119–30.

    Article  PubMed  Google Scholar 

  62. Shutter LA, Timmons SD. Intracranial pressure rescued by decompressive surgery after traumatic brain injury. New Engl J Med. 2016;375:1183–4.

    Article  PubMed  Google Scholar 

  63. Schlifka B. A neurosurgical perspective. J Trauma. 2010;62:S103–4.

    Article  Google Scholar 

  64. Howard JL, Cipolle MD, Anderson M, Sabella V, Shollenberger D, Li PM, et al. Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury. J Trauma. 2008;65(2):380–5.

    Article  PubMed  Google Scholar 

  65. Temkin NR, Haglund MM, Winn HR. Causes, prevention, and treatment of post-traumatic epilepsy. New Horiz. 1995;3:518–22.

    CAS  PubMed  Google Scholar 

  66. Temkin NR. Antiepileptogenesis and seizure prevention trials with antiepileptic drugs: meta-analysis of controlled trials. Epilepsia. 2001;42:515–24.

    Article  CAS  PubMed  Google Scholar 

  67. Naidech AM, Kreiter KT, Janjua N, Ostapkovich N, Parra A, Commichau C, et al. Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage. Stroke. 2005;36:583–7.

    Article  CAS  PubMed  Google Scholar 

  68. Clinical Trials. http://clinicaltrials.gov. 2011.

  69. Wang H, Gao J, Lassiter TF, McDonagh DL, Sheng H, Warner DS, et al. Levetiracetam is neuroprotective in murine models of closed head injury and subarachnoid hemorrhage. Neurocrit Care. 2006;5:71–8.

    Article  CAS  PubMed  Google Scholar 

  70. Kirmani BF, Mungall D, Ling G. Role of intravenous levetiracetam in seizure prophylaxis of severe traumatic brain injury patients. Front Neurol. 2013;4:170–81.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Rogers FB, Cipolle MD, Velmahos G, Rozycki G, Luchette FA. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group. J Trauma. 2002;53:142–64.

    Article  PubMed  Google Scholar 

  72. Marion DW. Head and spinal cord injury. Neurol Clin. 1998;16:485–502.

    Article  CAS  PubMed  Google Scholar 

  73. Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA. 2014;312:36–47.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  74. Juhasz M, Herszenyi L, Tulassay Z. Current Standings of the proton pump inhibitor and Clopidogrel Co-therapy: review on evolving field with the eyes of the gastroenterologist. Digestion. 2009;81(1):10–5.

    Article  PubMed  CAS  Google Scholar 

  75. Ropper AH, Gress DR, Diringer MN, et al. Neurological and neurosurgical intensive care. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2004.

    Google Scholar 

  76. Brainscope announces FDA has cleared the company to market AHEAD 300 for use in assessing traumatic brain injury. www.brainscope.com. 26 Sept 2016.

  77. Wali B, Ishrat T, Atif F, Hua F, Stein DG, Sayeed I. Glibenclamide administration attenuates infarct volume, hemispheric swelling, and functional impairments following permanent focal cerebral ischemia in rats. Stroke Res Treat. 2012;2012:460909.

    PubMed  PubMed Central  Google Scholar 

  78. Simard JM, Sheth KN, Kimberly WT, Stern BJ, del Zoppo GJ, Jacobson S, Gerzanich V. Glibenclamide in cerebral ischemia and stroke. Neurocrit Care. 2014;20(2):319–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  79. Zweckberger K, Hackenberg K, Jung CS, Hertle DN, Kiening KL, Unterberg AW, et al. Glibenclamide reduces secondary brain damage after experimental traumatic brain injury. Neuroscience. 2014;272:199–206.

    Article  CAS  PubMed  Google Scholar 

  80. Sheth KN, Elm JJ, Molyneaux BJ, Hinson H, Beslow LA, Sze GK, et al. Safety and efficacy of intravenous glyburide on brain swelling after large hemispheric infarction (GAMES-RP): a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol. 2016;15(11):1160–9.

    Article  CAS  PubMed  Google Scholar 

  81. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk of hospital-acquired pneumonia. JAMA. 2009;307:2120–8.

    Article  Google Scholar 

  82. Maas AIR, Roozenbeek B, Manley GT. Clinical trials in traumatic brain injury: past experience and current developments. Neurotherapeutics. 2010;7:115–26.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA

    Geoffrey Ling

  2. Critical Care Medicine and Vascular Neurology, Department of Neurology, Intermountain Medical Center, Murray, UT, USA

    Scott A. Marshall Jr

  3. Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of Health Sciences, Bethesda, MD, USA

    Randy S. Bell

  4. Department of Neurosurgery, MedStar Washington Hospital Center/Georgetown University Hospital, Washington, DC, USA

    Rocco A. Armonda

Authors
  1. Geoffrey Ling
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Scott A. Marshall Jr
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Randy S. Bell
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rocco A. Armonda
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Geoffrey Ling .

Editor information

Editors and Affiliations

  1. The University of Tennessee Health Science Center, Memphis, TN, USA

    Jack W. Tsao

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ling, G., Marshall, S.A., Bell, R.S., Armonda, R.A. (2020). Management of Moderate and Severe TBI. In: Tsao, J. (eds) Traumatic Brain Injury. Springer, Cham. https://doi.org/10.1007/978-3-030-22436-3_4

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-22436-3_4

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-22435-6

  • Online ISBN: 978-3-030-22436-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation