Abstract and Introduction
Abstract
Traumatic brain injury (TBI) remains a major public health problem. This review aims to present the principles upon which modern TBI management should be based. The early management phase aims to achieve haemodynamic stability, limit secondary insults (eg hypotension, hypoxia), obtain accurate neurological assessment and appropriately select patients for further investigation. Since 2003, the mainstay of risk stratification in the UK emergency departments has been a system of triage based on clinical assessment, which then dictates the need for a CT scan of the head. For patients with acute subdural or extradural haematomas, time from clinical deterioration to operation should be kept to a minimum, as it can affect their outcome. In addition, it is increasingly recognised that patients with severe and moderate TBI should be managed in neuroscience centres, regardless of the need for neurosurgical intervention. The monitoring and treatment of raised intracranial pressure is paramount for maintaining cerebral blood supply and oxygen delivery in patients with severe TBI. Decompressive craniectomy and therapeutic hypothermia are the subject of ongoing international multi-centre randomised trials. TBI is associated with a number of complications, some of which require specialist referral. Patients with post-concussion syndrome can be helped by supportive management in the context of a multi-disciplinary neurotrauma clinic and by patient support groups. Specialist neurorehabilitation after TBI is important for improving outcome.
Introduction
Traumatic brain injury (TBI) is an insult or trauma to the brain caused by external mechanical forces, whereas head injury is a generic term referring to injuries affecting not only the brain but also other structures of the head. In the UK, every year 1500 per 100 000 of the population (total 900 000) attend emergency departments with a head injury, 225–300 per 100 000 are admitted to hospital, 10–15 per 100 000 are admitted to neurosurgical units (NSUs) and 6–10 per 100 000 die from TBI. An estimated 1.2 million people live with some level of TBI-related disability in the UK, which has profound socioeconomic consequences, as the prevalence is particularly high among children and young to middle-aged adults. Clinicians from many hospital specialties, general practitioners and allied healthcare professionals are regularly involved in providing direct care during the various phases of the treatment pathway for head-injured patients. This review aims to present the principles upon which modern TBI management should be based, using 12 practical questions.