Traumatic brain injury (moderate-severe)MANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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610 items

☷ Legend

01Approach to the Critical Patient/attcp84

Primary survey and immediate threats

›Time-critical stabilization priorities

›Airway protection indications

›Glasgow Coma Scale 8 or less

›Refractory hypoxemia

›Refractory hypercapnia

›Recurrent vomiting with depressed consciousness

›Agitation preventing safe evaluation or imaging

›Cervical spine protection

›Manual in-line stabilization during airway management

›Rigid collar until clearance

›Oxygenation targets

›SpO2 94% to 98%

›Avoid SpO2 under 90%

›Ventilation targets

›PaCO2 35 to 40 mmHg when stable

›If herniation physiology, temporary PaCO2 30 to 35 mmHg until definitive therapy

›Hemodynamic targets

›SBP 110 mmHg or higher for age 15 to 49 years

›SBP 100 mmHg or higher for age 50 to 69 years

›SBP 110 mmHg or higher for age 70 years or older

›Glucose targets

›6 to 10 mmol/L

›Avoid hypoglycemia

›Avoid persistent hyperglycemia

›Temperature targets

›Normothermia

›Avoid fever

›Immediate escalation triggers

›Unilateral fixed dilated pupil

›Bilateral fixed dilated pupils

›New focal neurologic deficit

›Rapid decline in Glasgow Coma Scale

›Cushing response

›Refractory hypotension

›Refractory hypoxemia

›Seizure with persistent altered consciousness

Secondary brain injury prevention bundle

›Neuroprotection bundle

›Head and neck positioning

›Head of bed 30 degrees

›Neutral neck alignment

›Avoid jugular venous compression

›Sedation and analgesia goals

›Ventilator synchrony

›Control agitation and coughing

›Reliable neurologic reassessment plan

›Fluid strategy

›Isotonic crystalloids

›Avoid hypotonic fluids

›Avoid dextrose boluses unless hypoglycemia

›Oxygen delivery and anemia

›Avoid hypoxemia

›Consider transfusion threshold individualized to bleeding and oxygenation

›Coagulopathy correction

›Rapid reversal for intracranial hemorrhage with anticoagulant exposure

›Platelet goal individualized for procedure and hemorrhage expansion risk

Intracranial hypertension and herniation first-pass actions

›Suspected intracranial hypertension actions

›Immediate nonpharmacologic measures

›Optimize oxygenation and ventilation targets

›Head elevation and neutral alignment

›Analgesia and sedation for coughing and agitation

›Maintain SBP target range

›Hyperosmolar selection

›Hypertonic saline favored with hypotension risk

›Mannitol avoided with hypotension or hypovolemia

›Hyperventilation constraints

›Bridge therapy only for herniation physiology

›Avoid prolonged prophylactic hyperventilation

›Definitive pathway triggers

›Neurosurgery activation for mass lesion or refractory ICP

›Emergent CT head if not already obtained

›ICU admission for invasive monitoring needs

Consultation, transfer, and monitoring

›Team activation and destination

›Trauma team activation for multi-system injury

›Neurosurgery consultation for moderate to severe TBI

›Transfer to neurosurgical center when indicated

›Need for ICP monitor or EVD

›Need for neurosurgical intervention

›No local neurocritical care capability

›Monitoring modalities

›Continuous ECG

›Continuous SpO2

›Frequent noninvasive BP or arterial line

›End-tidal CO2 for ventilated patients

›Core temperature monitoring for ICU-level care

02History/hx67

Mechanism and timeline

›Event and timing

›Time of injury

›Time last known well

›Duration of loss of consciousness

›Mechanism details

›High-energy mechanism

›Fall height estimate

›Assault details

›Penetrating mechanism

›Blast exposure

›Prehospital course

›Hypoxia episodes

›Hypotension episodes

›Seizure activity

›Intubation and medications given

›Symptom progression

›Worsening headache

›Repeated vomiting

›Increasing confusion

›New weakness

›Vision changes

›Somnolence

Baseline function and risk modifiers

›Patient baseline

›Baseline cognition and function

›Dementia or neurocognitive disorder

›Baseline focal deficits

›Prior neurologic history

›Prior traumatic brain injury

›Seizure disorder

›Stroke history

›Neurosurgical history

›Bleeding risk history

›Liver disease

›Bleeding diathesis

›Thrombocytopenia history

Medications and exposures

›Medication and toxin profile

›Anticoagulants

›Warfarin

›Direct factor Xa inhibitor

›Direct thrombin inhibitor

›Antiplatelet agents

›Acetylsalicylic acid

›P2Y12 inhibitor

›Sedatives and opioids

›Benzodiazepine exposure

›Opioid exposure

›Alcohol and drugs

›Alcohol use preceding injury

›Stimulant exposure

›Opioid exposure

›Cannabis or other intoxicants

Associated injuries and symptoms

›Co-injuries and symptom clusters

›Neck pain

›Midline tenderness

›Neurologic symptoms in limbs

›Chest or abdominal pain

›Dyspnea

›Abdominal tenderness

›Long-bone pain

›Pelvic pain

›Back pain

›CSF leak symptoms

›Clear rhinorrhea

›Clear otorrhea

›Otologic symptoms

›Hearing loss

›Vertigo

03Physical Exam/exam55

Neurologic assessment

›Neurologic status and trends

›Level of consciousness

›Glasgow Coma Scale components

›Serial Glasgow Coma Scale trend

›Pupils

›Size and symmetry

›Reactivity

›Relative afferent pupillary defect

›Brainstem function

›Corneal reflex

›Gag reflex when appropriate

›Cough reflex when intubated

›Motor exam

›Symmetry of movement

›Focal weakness

›Posturing pattern

›Sensory exam

›Gross asymmetry when reliable

›Signs of herniation

›Unilateral fixed dilated pupil

›Bilateral fixed dilated pupils

›Decorticate posturing

›Decerebrate posturing

›Cushing response

Trauma survey and head and neck findings

›Head and neck injury findings

›Scalp and skull

›Lacerations

›Hematomas

›Palpable step-off

›Basilar skull fracture signs

›Periorbital ecchymosis

›Mastoid ecchymosis

›Hemotympanum

›CSF otorrhea or rhinorrhea

›Cervical spine

›Midline tenderness

›Deformity

›Neurologic symptoms suggesting spinal cord injury

›Facial trauma

›Orbital injury signs

›Midface instability

Physiology and systemic contributors

›Vital signs and systemic threats

›Blood pressure adequacy

›Persistent hypotension differential beyond isolated TBI

›Hemorrhagic shock screening

›Oxygenation

›SpO2 trend

›Work of breathing

›Ventilation

›End-tidal CO2 alignment with targets

›Temperature

›Fever source evaluation

›Skin and perfusion

›Capillary refill

›Peripheral perfusion

04Differential Diagnosis/ddx33

Primary intracranial injury patterns

›Intracranial traumatic diagnoses

›Intracranial hemorrhage

›Epidural hematoma (S06.4)

›Acute subdural hematoma (S06.5)

›Traumatic subarachnoid hemorrhage (S06.6)

›Intraparenchymal contusion or hemorrhage (S06.3)

›Intraventricular hemorrhage

›Diffuse injury

›Diffuse axonal injury (S06.2)

›Traumatic cerebral edema (S06.1)

›Skull fractures

›Linear skull fracture (S02.0)

›Depressed skull fracture (S02.1)

›Basilar skull fracture (S02.1)

Mimics and contributors to depressed consciousness

›Nontraumatic or mixed etiologies

›Toxicologic

›Alcohol intoxication (F10.129)

›Opioid intoxication (T40.2)

›Sedative hypnotic intoxication (T42)

›Metabolic

›Hypoglycemia (E16.2)

›Hyperglycemic crisis (E10.10, E11.10)

›Hyponatremia (E87.1)

›Hypercapnia

›Neurologic emergencies

›Status epilepticus (G40.901)

›Ischemic stroke (I63)

›Intracerebral hemorrhage (I61)

›Meningitis or encephalitis (G00, G04)

›Shock states

›Hemorrhagic shock (R57.1)

›Sepsis (A41.9)

›Cardiogenic shock (R57.0)

05Laboratory Tests/lt36

Core trauma and neurocritical labs

›Immediate lab panel

›Hematology

›Complete blood count for anemia and platelet count

›Platelet count threshold considerations

›Chemistry

›Sodium for osmotherapy planning

›Potassium for arrhythmia risk

›Creatinine for contrast and medication dosing

›Serum osmolality when using hyperosmolar therapy

›Glucose

›Point-of-care glucose

›Target range 6 to 10 mmol/L

›Coagulation

›INR for warfarin effect

›aPTT for heparin effect

›Fibrinogen for trauma-associated coagulopathy

›Blood bank

›Type and screen

›Crossmatch when hemorrhage suspected

Blood gas and ventilation monitoring

›Oxygenation and ventilation assessment

›Arterial blood gas when ventilated or unstable

›PaO2 confirmation for hypoxemia

›PaCO2 confirmation for ventilation targeting

›Lactate and perfusion

›Lactate for shock screening and resuscitation tracking

Focused adjunct labs

›Targeted labs by context

›Toxicology

›Blood alcohol concentration

›Urine drug screen when it changes management

›Pregnancy testing

›Beta hCG for pregnancy-capable patients

›Anticoagulant assessment

›Anti-Xa level when available for factor Xa inhibitor exposure

›Thrombin time when available for dabigatran exposure

›Viscoelastic testing

›Thromboelastography or rotational thromboelastometry for trauma coagulopathy when available

06Diagnostic Tests/dt50

Scoring Systems

›Clinical and imaging scores

›Glasgow Coma Scale

›Moderate traumatic brain injury range 9 to 12

›Severe traumatic brain injury range 3 to 8

›Pupillary reactivity

›Bilateral nonreactive pupils as poor prognostic sign

›Unilateral nonreactive pupil as herniation risk marker

›CT classification frameworks

›Marshall CT classification for diffuse injury versus mass lesion patterns

›Rotterdam CT score for outcome prediction

›Physiologic risk framing

›Hypotension and hypoxemia as major secondary injury modifiers

MRI

›MRI brain applications

›Indications after CT

›Suspected diffuse axonal injury with disproportionate exam

›Persistent coma without clear CT explanation

›Brainstem injury concern

›Sequences and targets

›Susceptibility weighted imaging for microhemorrhage

›Diffusion weighted imaging for axonal injury patterns

›Limitations

›Time and transport risk in unstable patients

›Implanted device contraindications

›CT-based diagnosis and triage

›Noncontrast CT head

›First-line imaging for suspected intracranial hemorrhage

›Mass effect assessment

›Midline shift assessment

›Basal cistern effacement assessment

›Repeat CT head strategy

›Neurologic deterioration trigger

›Post-procedure trigger

›High-risk hemorrhage expansion context

›CT cervical spine

›High-risk mechanism

›Altered mental status preventing reliable exam

›CTA head and neck

›Cervical vascular injury risk pattern

›Basilar skull fracture involving carotid canal

›High-risk cervical spine fracture patterns

Ultrasound

›Ultrasound adjuncts

›Extended FAST

›Hemorrhagic shock screening in multi-trauma

›Pneumothorax screening

›Optic nerve sheath diameter

›Screening adjunct for elevated ICP physiology

›Not a replacement for CT and invasive monitoring

›Cardiac ultrasound

›Shock differential support

›Pericardial effusion screening in trauma context

07Disposition/dispo30

Level of care and admission criteria

›Destination planning

›ICU admission indications

›Moderate or severe traumatic brain injury with CT abnormality

›Need for mechanical ventilation

›Need for vasoactive support

›Need for frequent neurologic checks

›Need for hyperosmolar therapy

›Neurosurgical admission indications

›Epidural hematoma

›Acute subdural hematoma

›Depressed skull fracture

›Intracranial hemorrhage with mass effect

›Penetrating head injury

›ICP monitoring pathway

›Severe traumatic brain injury with abnormal CT

›Severe traumatic brain injury with normal CT plus risk features

›Age over 40 years

›Unilateral or bilateral motor posturing

›SBP under 90 mmHg at admission

Transfer criteria and timing

›Transfer to higher level care

›Immediate transfer triggers

›Need for neurosurgical intervention unavailable locally

›Need for ICP monitor or EVD unavailable locally

›Refractory intracranial hypertension

›Polytrauma requiring trauma center resources

›Transport stabilization targets

›Secure airway and ventilation targets

›Hemodynamic targets met

›Hyperosmolar therapy available during transport when indicated

›Sedation plan to prevent coughing and agitation

08Treatment/t138

Airway, ventilation, and oxygenation

›Airway and ventilation strategy

›Induction and paralysis considerations

›Hemodynamic stability prioritization

›Cervical spine protection technique

›Ventilator targets

›PaCO2 35 to 40 mmHg

›PaO2 adequate for SpO2 94% to 98%

›Rescue hyperventilation pathway

›If herniation physiology, temporary PaCO2 30 to 35 mmHg

›Stop rescue hyperventilation after definitive ICP therapy and stabilization

Hemodynamics and perfusion

›Blood pressure and perfusion support

›SBP thresholds

›Age 15 to 49 years SBP 110 mmHg or higher

›Age 50 to 69 years SBP 100 mmHg or higher

›Age 70 years or older SBP 110 mmHg or higher

›Vasopressor strategy when fluids insufficient

›Norepinephrine infusion

›Start 0.05 microg/kg/min

›Titrate every 2 to 5 minutes to SBP target

›Typical range 0.05 to 1 microg/kg/min

›Avoidances

›Hypotension

›Excess crystalloid causing pulmonary edema

›Hypotonic fluid

Intracranial pressure control and herniation treatment

›Stepwise ICP control

›Nonpharmacologic measures

›Head elevation 30 degrees

›Neutral neck alignment

›Analgesia and sedation optimization

›Normothermia

›PaCO2 35 to 40 mmHg

›Hyperosmolar therapy

›Hypertonic saline bolus options

›Sodium chloride 3% IV 2 to 3 mL/kg bolus

›Repeat bolus by clinical response and sodium trend

›Sodium monitoring every 2 to 4 hours when actively dosing

›Sodium chloride 23.4% IV 0.5 mL/kg

›Maximum 30 mL dose

›Central access preferred

›Continuous ECG monitoring

›Mannitol option

›Mannitol IV 0.25 g/kg to 1 g/kg

›Avoid if hypotension or hypovolemia

›Serum osmolality monitoring and renal function monitoring

›Pre-ICP monitor use limited to herniation physiology or progressive deterioration without extracranial cause

›CSF diversion

›External ventricular drain

›Continuous drainage strategy when used

›Level III recommendation language for continuous drainage in severe TBI

›Sedation escalation

›Propofol infusion

›Start 5 to 10 microg/kg/min

›Titrate by 5 to 10 microg/kg/min every 5 to 10 minutes

›Typical upper range 50 to 80 microg/kg/min

›Hypotension risk and propofol infusion syndrome awareness

›Midazolam infusion

›Start 0.02 to 0.1 mg/kg/hour

›Titrate to ventilator synchrony and ICP control

›Analgesia adjunct

›Fentanyl infusion

›Start 1 microg/kg/hour

›Titrate to comfort and ventilator synchrony

›Refractory ICP rescue

›Neuromuscular blockade as short-term adjunct

›Rocuronium bolus 1 mg/kg

›Continuous infusion if required with deep sedation

›Barbiturate coma consideration with neurosurgical and ICU coordination

›Continuous EEG monitoring requirement

›Decompressive craniectomy pathway

›Neurosurgery-led decision for refractory intracranial hypertension

Cerebral perfusion targets

›ICP and CPP targets

›ICP threshold treatment target

›Treat ICP above 22 mmHg

›Level II B recommendation language for ICP threshold 22 mmHg

›CPP target range

›60 to 70 mmHg target

›Avoid aggressive CPP over 70 mmHg with fluids and pressors

›Monitoring alignment

›Arterial line for vasoactive titration

›End-tidal CO2 monitoring for ventilation targets

Seizure management and prophylaxis

›Seizure pathway

›Acute seizure treatment

›Lorazepam IV 0.1 mg/kg

›Maximum 4 mg per dose

›Repeat once after 5 minutes if ongoing seizure

›If refractory, antiseizure loading

›Levetiracetam IV 60 mg/kg

›Maximum 4500 mg

›Fosphenytoin IV 20 mg PE/kg

›Maximum 1500 mg PE

›Early post-traumatic seizure prophylaxis

›Indication framing

›Severe traumatic brain injury

›Intracranial hemorrhage on CT

›Depressed skull fracture

›Penetrating head injury

›Levetiracetam regimen

›Levetiracetam IV 1000 mg load

›Then 1000 mg every 12 hours

›Duration 7 days

›Renal dosing adjustment when needed

›Phenytoin regimen alternative

›Phenytoin IV 15 to 20 mg/kg load

›Then 100 mg every 8 hours

›Level monitoring as locally available

›Duration 7 days

Coagulopathy and anticoagulant reversal

›Hemorrhage expansion risk reduction

›Warfarin-associated intracranial hemorrhage

›4-factor PCC dosing by INR and weight per local protocol

›Typical 25 to 50 units/kg based on INR category

›Vitamin K IV 10 mg

›Slow infusion to reduce reaction risk

›Factor Xa inhibitor associated intracranial hemorrhage

›Andexanet alfa when available and indicated by agent and timing

›Dosing per specific agent and last dose timing

›If andexanet not available, 4-factor PCC per local protocol

›Dabigatran associated intracranial hemorrhage

›Idarucizumab IV 5 g

›Two 2.5 g doses

›Antiplatelet exposure considerations

›Desmopressin IV 0.3 microg/kg for life-threatening bleeding consideration

›Platelet transfusion individualized for neurosurgical procedure planning

›Thrombocytopenia

›Platelet transfusion threshold individualized for bleeding and procedure needs

DVT prophylaxis and supportive ICU care

›ICU supportive care bundle

›Venous thromboembolism prevention

›Mechanical prophylaxis when bleeding risk present

›Pharmacologic prophylaxis timing after stable head CT with neurosurgery input

›Stress ulcer prevention

›ICU indication-based prophylaxis

›Nutrition

›Early enteral nutrition when feasible

›Skin and eye care

›Corneal protection in ventilated patients

›Pressure injury prevention

›Delirium mitigation framework

›Sedation minimization when safe

›Day-night cycling in ICU

09Special Populations/sp35

Pregnancy

›Pregnancy-specific considerations

›Maternal stabilization priority

›Oxygenation and SBP targets to protect uteroplacental perfusion

›Left uterine displacement in late pregnancy when supine

›Imaging considerations

›CT head when clinically indicated

›Radiation counseling and shielding practices per local protocol

›Medication considerations

›Hyperosmolar therapy risk-benefit framing with multidisciplinary input

›Antiseizure medication selection balancing maternal stability and fetal considerations

›Obstetric coordination

›Fetal monitoring when viable gestational age

›Rh immunoglobulin for Rh-negative trauma patients per obstetric guidance

Geriatric

›Older adult considerations

›Anticoagulant and antiplatelet prevalence

›Low threshold for reversal pathway activation with intracranial hemorrhage

›Brain atrophy effect

›Delayed symptom progression risk

›Subdural hematoma risk pattern

›Comorbidity burden

›Blood pressure support balancing cardiac disease

›Polypharmacy interactions

›Goals of care

›Early discussion when severe injury and poor prognosis markers present

Pediatrics

›Pediatric considerations

›Age-specific physiology

›Weight-based dosing for hyperosmolar therapy and antiseizure therapy

›Higher risk of abusive head trauma in infants and toddlers

›Imaging thresholds and sedation needs

›Transport and monitoring planning for CT and MRI

›Hypertonic saline dosing

›Sodium chloride 3% IV 2 to 5 mL/kg bolus

›Sodium monitoring frequency aligned with active therapy

›Child protection pathway

›Safeguarding consultation when mechanism inconsistent or concerning findings present

10Background/b44

Epidemiology

›Epidemiology and burden

›Common mechanisms

›Falls

›Motor vehicle collision

›Assault

›Sports and recreation

›Severity categories

›Moderate traumatic brain injury as Glasgow Coma Scale 9 to 12

›Severe traumatic brain injury as Glasgow Coma Scale 3 to 8

›Outcome drivers

›Secondary brain injury from hypotension and hypoxemia

›Intracranial hypertension and herniation

›Coagulopathy and hemorrhage expansion

Pathophysiology

›Injury mechanisms

›Primary injury

›Contusion and laceration

›Diffuse axonal injury

›Vascular disruption and hemorrhage

›Secondary injury cascade

›Excitotoxicity

›Mitochondrial dysfunction

›Neuroinflammation

›Cerebral edema

›Monro-Kellie doctrine implications

›Compensatory reserve exhaustion

›Rapid ICP rise after reserve exhaustion

›Herniation syndromes

›Uncal herniation with ipsilateral pupil dilation

›Central herniation with progressive coma

Therapeutic Considerations

›Therapeutic rationale and evidence framing

›ICP threshold management

›ICP above 22 mmHg associated with increased mortality

›Treating ICP above 22 mmHg recommended at Level II B

›CPP optimization

›CPP target 60 to 70 mmHg as Level II B

›Autoregulation status influence on optimal CPP target

›Blood pressure thresholds

›Age-stratified SBP thresholds as Level III recommendation

›Hyperosmolar therapy role

›Rapid reduction in ICP as bridge to definitive management

›Agent selection influenced by hemodynamics and renal function

›Ventilation strategy

›Normocapnia as default

›Hyperventilation as time-limited bridge for herniation physiology

11Patient Discharge Instructions/pdi25

Copy discharge instructions

›Discharge instructions for hospitalized moderate to severe TBI survivors

›Safety and supervision

›Adult supervision until cleared by treating team

›No driving until cleared

›No alcohol or recreational drugs

›Activity restrictions

›No contact sports until cleared

›Gradual return to activity under clinician guidance

›Medication guidance

›Take prescribed antiseizure medication exactly as directed

›Avoid sedatives unless prescribed

›Return immediately for

›Worsening headache

›Repeated vomiting

›New weakness or numbness

›New confusion or agitation

›Seizure

›Difficulty waking up

›New vision changes

›Clear fluid from nose or ear

›Fever with worsening mental status

›Follow-up planning

›Neurosurgery or trauma clinic appointment as scheduled

›Rehabilitation assessment when recommended

›Cognitive and mood symptom screening follow-up

12References/r13

Clinical guidelines and protocols

›Evidence-based guidelines and protocols

›Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury

›ICP threshold treatment recommendation 22 mmHg

›CPP target recommendation 60 to 70 mmHg

›SBP threshold recommendations by age category

›Emergency Neurological Life Support protocols

›Traumatic Brain Injury protocol

›Intracranial Hypertension and Herniation protocol

›Pharmacotherapy protocol for hyperosmolar dosing

Key studies and evidence summaries

›Supporting evidence base

›Comparative studies of levetiracetam versus phenytoin for early post-traumatic seizure prevention

›Hyperosmolar therapy systematic reviews for ICP reduction

›Trauma registry analyses linking hypotension thresholds to mortality in TBI

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.