Traumatic brain injury

Traumatic brain injury (TBI) refers to the potential for significant injury to the brain parenchyma following head trauma. This article covers pertinent principles, management approaches, and current controversies in severe, moderate, and minor TBI. Controversies covered include hypertonic saline (HTS) for increased intracranial pressure (ICP), prehospital intubation of patients who have experienced TBI, and the use of recombinant factor VIIa (rFVIIa). Traumatic head injury has plagued humankind since the beginning of civilization. The writings of Hippocrates refer to trephination [1], and early writings on the practice of neurosurgery describe the management of head trauma. Although the most common mechanism for TBI has changed since antiquity from assaults to motor vehicle-associated injuries, TBI remains the single largest cause of trauma morbidity and accounts for nearly one third of all trauma deaths (Fig. 1) [2-4]. An estimated 1.1 million patients are evaluated each year in emergency departments for acute TBI [3]. TBI occurs most. often in young people, with a peak incidence at 15 to 24 years of age [4]. Smaller peaks occur in children younger than 5 years of age and in individuals older than 85 years [4]. Child abuse is common in children younger than 4 years of age who present with severe to moderate TBI (Fig. 2) [5]. TBI is commonly categorized by means of the Glasgow Coma Scale (GCS) [6] as severe (GCS <= 8), moderate (GCS 9-13), and minor (GCS 14-15). Severe TBI accounts for approximately 10% of all cases, whereas moderate TBI accounts for another 10%; the remaining 80% are classified as minor [4].