Management of traumatic brain injury

Traumatic brain injury (TBI) is a complex disease process that requires constant attention as one manages the associated body systems. Even though an "isolated" brain injury may be the cause for admission to the hospital, the injured brain cannot be thought of in isolation from the remainder of the body. All body systems, from cardiac to pulmonary, need to be addressed as one moves from the initial to the long-term management of the TBI. The multiple issues are best addressed with a dedicated neurocritical care team that is in continuous communication with the neurosurgical team throughout the course of treatment. To date, no pharmacologic treatment has led to improved outcomes after TBI, but it is becoming increasingly clear that advances in the critical care of TBI patients are contributing to better results.During resuscitation of the TBI patient, medical management in its simplest form strives to return measurable vital signs and laboratory values (eg, intracranial pressure, mean arterial pressure, blood glucose, PaO(2), or PaCO(2)) to their normal range. The initial goal is to maintain or reestablish normal homeostasis.The initial injury to the brain is irreversible by any medical modalities available today. After the initial resuscitation, medical maneuvers are directed at limiting secondary damage to the brain. Secondary brain injury occurs in response to inflammatory changes, expanding hematomas, cellular swelling, seizures, and systemic complications (ie, hemodynamic or pulmonary changes, fever, pain); vulnerable surrounding brain tissue can be damaged through alterations in cerebral perfusion and metabolism. Treatments to address these issues include, but are not limited to, analgesics, sedatives, anticonvulsants, hyperosmotic agents, and hypothermia.The future of TBI care likely lies in the areas of better injury classification to guide therapeutic interventions, management of secondary injury, improved technology for intracranial monitoring, and regeneration/rehabilitation. Studies focusing on signaling pathways, neural stem cells, and reparative medications are all in the early stages of development; their use is currently experimental at best.There are few areas in medicine where clinicians have the opportunity to impact a patient's life to the degree seen in the management of TBI. Although parts of the proverbial puzzle certainly remain unsolved, it is the remarkable recoveries that patients make with the therapeutic modalities available today that keep management of TBI one of the most exciting areas in medicine.