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==Background==
*Traumatic Brain Injury (TBI)
**Impairment in brain function from mechanical force

*Main goals in management:
**Prevent intracranial hypertension
**Prevent secondary brain insults
**Maintain Cerebral Perfusion Pressure (CPP) > 70 mmHg
**Optimize cerebral oxygenation and blood flow
*Severe TBI defined as head trauma and GCS 3-8<ref>Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet. 1974, 2: 81-84.</ref>
[[File:TBI GCS.jpg|thumb]]

==Clinical Features==
{{GCS table}}
==Pathophysiology==

*vasoconstriction
**HTN, Hypocarbia, alkalosis
*No good way to measure cerebral blood flow
**Use CPP as surrogate
***CPP is amount of pressure needed to perfuse the brain
***CPP=MAP-ICP
****When ICP elevates, CPP decreases
****Normal ICP 
*****15 in adults
*****<10 to 15 in children
*****1.5 to 6.0 in infants

*Autoregulation allows the body to control the cerebral blood flow
**Autoregulatory mechanism is damaged in most TBI patients
*Cushing Reflex- more common in children than adults
**Hypertension
**Bradycardia
**Respiratory Irregularity

==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}

{{Maxillofacial trauma DDX}}

{{Blunt neck trauma DDX}}

===Other===
*[[Concussion]]
*[[Severe traumatic brain injury]]

==Evaluation==
{{Head trauma workup}}
*Pertinent labs
*Blood glucose
*Venous blood  
*Hemoglobin assessment with consideration for transfusion with Hb < 7 mg/dL
*PT/INR/PTT
*Electrolytes
**[[Hyponatremia]], hypomagnesemia, and hypophosphatemia may lower the seizure threshold
*Miscellaneous labs
**Beta-2 transferrin for CSF leak, needs 0.5 cc of fluid<ref>Arup Laboratories. https://arupconsult.com/content/cerebrospinal-fluid-csf-leak-beta-2-transferrin.</ref>
===Monitoring===
*Core temperature, Foley with bladder probe
*ICP monitoring
*Jugular venous oxygen saturation (SjvO2) by retrograde catherization of right IVJ associated with improved outcomes<ref>Cruz J: The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management strategies and clinical outcome. Crit Care Med. 1998, 26: 344-351.</ref>
**Normal range 55-70%
**Sustained desaturation < 50% requires aggressive treatment<ref>Robertson CS, Cormio M: Cerebral metabolic management. New Horiz. 1995, 3: 410-422.</ref>
*Transcranial doppler around thinner walls of skull (insonation windows)<ref>de Freitas GR, Andre C: Sensitivity of transcranial Doppler for confirming brain death: A prospective study of 270 cases. Acta Neurol Scand. 2006, 113: 426-432.</ref><ref>Dosemeci L, Dora B, Yilmaz M, et al: Utility of transcranial Doppler ultrasonography for confirmatory diagnosis of brain death: Two sides of the coin. Transplantation. 2004, 77: 71-75.</ref>
**Temporal region above zygomatic arch, through eyes, below jaw, behind occiput
**Sensitivity for brain death is ~75%, specificity 98%

==Management==
*Monitor for increased ICP 
*Monitor for [[Brain herniation syndromes|herniation]]
*Maintain PaO2 > 60 mmHg
*Prevent hyperthermia
*Prevent hypotension
*Correct coagulopathy (FFP, vitamin K, PCC, desmopressin)
*[[Tranexemic acid]] may reduce progressive ICH<ref>Yutthakasemsunt S et al. Tranexamic Acid for Patients With Traumatic Brain Injury. BMC Emerg Med. 2013;13.</ref>
**Loading dose 1 g over 10 min
**Followed by maintenance dose of 1 g over 8 hrs

{{Increased ICP treatment}}

==See Also==
*[[Pediatric head trauma]]

==References==
<references/>

[[Category:Trauma]]
[[Category:Neurology]]