Evidence-based guideline for classification, imaging decisions, ICP management, surgical indications, and outcome prediction in traumatic brain injury across all severity levels.
A comprehensive, evidence-based clinical guideline for the emergency department evaluation, neurocritical care, and long-term management of traumatic brain injury across all severity levels — from concussion through severe TBI requiring decompressive craniectomy. This resource synthesizes recommendations from the major neurotrauma foundations, trauma quality improvement programs, emergency medicine professional societies, international head injury organizations, and sport concussion consensus groups into a single integrated reference for emergency physicians, trauma surgeons, neurosurgeons, neurointensivists, and advanced practice providers who manage patients with acute head injury.1 2 3 4 5 6 7 8
Traumatic brain injury remains a leading cause of death and disability worldwide, accounting for approximately 2.5 million emergency department visits, 288,000 hospitalizations, and 57,000 deaths annually in the United States alone. Globally, TBI affects an estimated 69 million individuals per year. The management of TBI has evolved substantially over the past two decades, driven by landmark randomized controlled trials (CRASH-3, DECRA, RESCUEicp, Eurotherm3235, BEST:TRIP) and the systematic development of evidence-based guidelines. The cornerstones of modern TBI care — structured severity classification, validated imaging decision rules, protocol-driven intracranial pressure management, timely surgical intervention, and evidence-based concussion management — form the basis of this guideline.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | TBI Classification & CT Imaging Decision Rules | GCS scoring (complete table); TBI classification by severity (mild, moderate, severe); mechanism-based classification; Canadian CT Head Rule (complete criteria); New Orleans Criteria (complete criteria); PECARN pediatric head CT algorithm (< 2 years and ≥ 2 years); comparison table of decision rules (sensitivity, specificity); CT interpretation and injury patterns |
| Part 2 | Initial Management & Resuscitation | Airway management and RSI in TBI; oxygenation and ventilation targets; blood pressure management and cerebral autoregulation; fluid resuscitation; seizure prophylaxis (levetiracetam vs phenytoin); coagulopathy in TBI; anticoagulant reversal protocols; TXA in TBI (CRASH-3 trial); cerebral herniation recognition and emergency management |
| Part 3 | ICP Management & Surgical Indications | ICP monitoring indications; ICP and CPP targets; tiered ICP management protocol (Tier 0 through Tier 3 with complete dosing); hyperosmolar therapy (mannitol, hypertonic saline); EVD and CSF drainage; decompressive craniectomy (DECRA, RESCUEicp evidence); barbiturate coma protocol; therapeutic hypothermia (Eurotherm3235); surgical indications for epidural hematoma, subdural hematoma, depressed skull fracture, and posterior fossa lesions |
| Part 4 | Specific Injury Types, Herniation & Advanced Monitoring | Epidural hematoma; acute and chronic subdural hematoma; traumatic subarachnoid hemorrhage; diffuse axonal injury; skull fractures (linear, depressed, basilar); penetrating TBI; cerebral herniation syndromes (uncal, central, tonsillar); advanced neuromonitoring (PbtO2, cerebral microdialysis, continuous EEG, transcranial Doppler); neurosurgical consultation criteria |
| Part 5 | Concussion, Special Populations & Prognosis | Concussion/mild TBI assessment (SCAT6); graded return-to-play protocol; return-to-learn guidelines; post-concussive syndrome; pediatric TBI management; geriatric TBI and anticoagulant-associated ICH; TBI in pregnancy; coagulopathy management; IMPACT and CRASH prognostic models; biomarkers (GFAP, UCH-L1, S100B, NSE); rehabilitation referral criteria |
Carney N, Totten AM, O’Reilly C, et al. “Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.” Neurosurgery. 2017;80(1):6-15. DOI: 10.1227/NEU.0000000000001432 ↩︎
Hawryluk GWJ, Rubiano AM, Totten AM, et al. “Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations.” Neurosurgery. 2020;87(3):427-434. DOI: 10.1093/neuros/nyaa278 ↩︎
ACS TQIP. “ACS TQIP Best Practices in the Management of Traumatic Brain Injury.” American College of Surgeons Trauma Quality Improvement Program. 2015. URL: https://www.facs.org/quality-programs/trauma/quality/best-practices-guidelines/ ↩︎
National Institute for Health and Care Excellence. “Head Injury: Assessment and Early Management (CG176).” NICE Guidelines. 2023. URL: https://www.nice.org.uk/guidance/cg176 ↩︎
Stiell IG, Wells GA, Vandemheen K, et al. “The Canadian CT Head Rule for patients with minor head injury.” Lancet. 2001;357(9266):1391-1396. DOI: 10.1016/S0140-6736(00)04561-X ↩︎
Haydel MJ, Preston CA, Mills TJ, et al. “Indications for computed tomography in patients with minor head injury.” N Engl J Med. 2000;343(2):100-105. DOI: 10.1056/NEJM200007133430204 ↩︎
Patricios JS, Schneider KJ, Dvorak J, et al. “Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport — Amsterdam, October 2022.” Br J Sports Med. 2023;57(11):695-711. DOI: 10.1136/bjsports-2023-106898 ↩︎
Kuppermann N, Holmes JF, Dayan PS, et al. “Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study (PECARN).” Lancet. 2009;374(9696):1160-1170. DOI: 10.1016/S0140-6736(09)61558-0 ↩︎
Concussion assessment (SCAT6), return-to-play and return-to-learn protocols, post-concussive syndrome, pediatric TBI, geriatric TBI, TBI in pregnancy, IMPACT and CRASH prognostic models, biomarkers (GFAP, UCH-L1, S100B, NSE), and rehabilitation referral criteria.
Epidural hematoma, acute and chronic subdural hematoma, traumatic subarachnoid hemorrhage, diffuse axonal injury, skull fractures, penetrating TBI, cerebral herniation syndromes, and advanced neuromonitoring including PbtO2, cerebral microdialysis, continuous EEG, and transcranial Doppler.
ICP monitoring indications, ICP and CPP targets, complete tiered ICP management protocol with dosing, hyperosmolar therapy, EVD drainage, decompressive craniectomy (DECRA, RESCUEicp), barbiturate coma, and surgical indications for epidural hematoma, subdural hematoma, depressed skull fracture, and posterior fossa lesions.
Airway management and RSI in TBI, oxygenation and ventilation targets, blood pressure management, seizure prophylaxis, coagulopathy reversal, TXA (CRASH-3), and cerebral herniation emergency management.
GCS scoring, TBI severity classification, Canadian CT Head Rule, New Orleans Criteria, PECARN pediatric head CT algorithm, and comparison of imaging decision rules with sensitivity and specificity data.