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Traumatic brain injury
In head injury the aim is to prevent secondary damage — avoiding hypoxia and hypotension is the most important treatment; GCS sets the severity, CT finds a haematoma that needs surgery, and in severe injury intracranial pressure is monitored and cerebral perfusion pressure maintained.
Why it matters in the exam
Questions start with classification: mild (GCS 13–15), moderate (9–12) and severe (8 or less) injury, and the decision on who needs CT — by the Canadian CT Head Rule: GCS below 15 two hours after injury, suspected open or depressed fracture, signs of basal skull fracture, two or more episodes of vomiting, or age 65 or older. Patients on anticoagulants have CT at a low threshold. Then the haematoma types are asked: epidural (middle meningeal artery, temporal fracture, "lucid interval", lens shape) and subdural (bridging veins, older patients, alcoholics and patients on anticoagulants, crescent shape).
In severe injury the treatment is asked: intubation at GCS 8 or less, avoiding hypotension (systolic target of 100 or more at age 50–69, and 110 or more at age 15–49 or above 70) and avoiding hypoxia; ICP monitoring and treatment when it rises above 22 mmHg; a cerebral perfusion pressure of 60–70; head elevation, hyperosmolar therapy (mannitol or hypertonic saline), and hyperventilation only as a brief bridge for herniation. Steroids must not be given in head injury. Signs of herniation: a dilated pupil on the side of the injury and contralateral weakness; Cushing's triad — hypertension, bradycardia and irregular breathing.
Key points
- GCS: mild 13–15, moderate 9–12, severe 8 or less.
- Epidural — artery, lens, lucid interval; subdural — veins, crescent, older patients.
- Preventing hypoxia and hypotension is the most important treatment.
- ICP above 22 — treat; perfusion pressure 60–70.
- No steroids; hyperventilation only as a brief bridge.
Summary table
| Topic | Finding | Action |
|---|---|---|
| Severity by GCS | Mild 13–15; moderate 9–12; severe 8 or less | 8 or less — intubation |
| Epidural haematoma | Middle meningeal artery, temporal fracture, lucid interval, lens shape | Surgical evacuation when the volume is above 30 cm³, regardless of GCS |
| Acute subdural haematoma | Bridging veins, older or anticoagulated patient, crescent shape | Evacuation when thickness is above 10 mm or midline shift above 5 mm |
| Intracranial pressure | Monitored in severe injury | Treat when the pressure is above 22 mmHg; cerebral perfusion pressure 60–70 |
| Herniation | Dilated pupil on the injured side, contralateral weakness; Cushing's triad | Hyperosmolar therapy, brief hyperventilation as a bridge and surgery |
| Anticoagulants | High bleeding risk | Low threshold for CT and immediate reversal of the anticoagulant |
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Sources
- Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury, 4th edition (2016) — Blood pressure, ICP and CPP thresholds, hyperosmolar therapy
- The Canadian CT Head Rule for patients with minor head injury (Stiell et al., The Lancet), 2001 — High- and medium-risk criteria
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Head Trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.