Evaluation and management of traumatic brain injury

Abstract

Traumatic brain injury is a common problem in the United States, affecting approximately 550,000 people annually. Patients with TBI should be evaluated by the ATLS protocol and serial GCS assessments, followed by a thorough neurologic exam when they are systemically stable. Head CT is the diagnostic imaging modality of choice in the evaluation of TBI, and MRI scanning is used only in special situations. Some patients with mild head injuries may not require CT scanning; however, patients with moderate or severe injuries must be evaluated with a CT scan. If no surgical lesion is present or following surgery if one is present, specific treatment of the head injury begins. Patients with a GCS of 8 or less require placement of an ICP monitor. If the ICP is elevated, these patients are treated with some or all of the following: CSF drainage, modest hyperventilation, and diuretics. These strategies are designed to decrease the volume of one of the three intracranial components (brain, blood, and CSF) in order to improve intracranial compliance and decrease ICP. If these strategies are not effective in controlling ICP, then other treatment modalities, such as barbiturate coma, hypothermia, or decompressive craniectomy, may be utilized. There are many potential neurologic complications of head injury including cranial nerve deficits, seizures, infections, hydrocephalus, and brain death. While patients with mild head injury usually do well, some of those who develop a postconcussive disorder are disabled permanently. It is very difficult to predict the outcome of moderate and severe head injuries, and most algorithms devised for this purpose do not reliably predict outcome. As expected, many of these patients have poor outcomes. © Springer Science+Business Media, Inc. 2005.