Traumatic brain injury (TBI) is the leading cause of death in North America for individuals between the ages of 1 to 45 [1,2]. Many survivors live with significant disabilities, resulting in major socioeconomic burden as well. In 2000, the economic impact of TBI in the United States was estimated to be $9.2 billion in lifetime medical costs and $51.2 billion in productivity losses.
One of the major advances over the past two decades in the care of patients with severe head injury has been the development of standardized approaches that follow international and national guidelines [3-6]. The intent of these guidelines has been to use existing evidence to provide recommendations for current care in order to lessen heterogeneity and improve patient outcomes. Unfortunately, the lack of randomized clinical trials addressing many aspects of care of the severe TBI patient has meant that the strength of supporting data for most treatment concepts is relatively weak. Despite this caveat, there is evidence that treatment in centers with neurosurgical support, especially in settings where protocol-driven neurointensive care units operate based on the above-referenced guidelines, is associated with better patient outcomes [7-14]. Many expert panels recommend that treatment of severe TBI should be centralized in large trauma centers that offer neurosurgical treatment and access to specialized neurocritical care.
Patients with severe head injury may frequently have other traumatic injuries to internal organs, lungs, limbs, or the spinal cord. Thus, the management of the patient with severe head injury is often complex and requires a multi-disciplinary approach and lends itself to protocol-based treatment and standardized hospital order sets derived from the previously referenced guidelines.
This topic discusses the management of acute severe traumatic brain injury. The epidemiology and pathophysiology of traumatic brain injury, the management of mild traumatic brain injury, acute spinal cord injury, and other aspects of care of the trauma patient are discussed separately. (See "Traumatic brain injury: Epidemiology, classification, and pathophysiology" and "Concussion and mild traumatic brain injury" and "Acute traumatic spinal cord injury" and "Skull fractures in adults".)
INITIAL EVALUATION AND TREATMENT
Prehospital — The primary goal of prehospital management for severe head injury is to prevent hypotension and hypoxia, two systemic insults known to be major causes of secondary injury after TBI [15-20]. In a meta-analysis of clinical trials and population-based studies, hypoxia (PaO2 <60 mmHg) and hypotension (systolic BP <90 mmHg) were present in 50 and 30 percent of patients, respectively, and were each associated with a higher likelihood of a poor outcome: hypoxia (OR 2.14); hypotension (OR 2.67) . Changes in prehospital management that aim to normalize oxygenation and blood pressure have improved outcomes [21-25]: