Clinical management of patients with head injury

Traumatic brain injury (TBI) is one of the major causes of disability, death and health related cost to our society. An organized trauma system from the site of accident to the Intensive Care Unit is the cornerstone of treatment of TBI patients. Treatment in the emergency room must focus on swift normalization of blood pressure and oxygenation. During tracheal intubation cervical spine protection and the risk of aspiration, must be balanced against the risk of hypotension and hypercapnia. Both hyper- and hypoventilation can be deleterious in TBI patients, and consequently, they should be normoventilated as guided by end-tidal CO2. A neurosurgeon should be consulted before a TBI patient is taken directly from the emergency room to emergency surgery for non-life threatening injuries and a intracranial pressure monitor should be inserted. Treatment goals include an intracranial pressure below 20mmHg and a cerebral perfusion pressure above 60mmHg. Choice of sedative and analgesics is of minor importance as long as the traumatic stress is blunted. Methylprednisolone in high doses should not be used in head injured patients. Special considerations must be taken in the treatment of children and the elderly.