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Critical care management of severe traumatic brain injury in adults

DOI: 10.1186/1757-7241-20-12

Keywords: Traumatic brain injury, head injury, head trauma, critical care

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Abstract:

Severe traumatic brain injury (TBI), defined as head trauma associated with a Glasgow Coma Scale (GCS) score of 3 to 8 [1], is a major and challenging problem in critical care medicine. Over the past twenty years, much has been learned with a remarkable progress in the critical care management of severe TBI. In 1996, the Brain Trauma Foundation (BTF) published the first guidelines on the management of severe TBI [2] that was accepted by the American Association of Neurological Surgeons and endorsed by the World Health Organization Committee in Neurotraumatology. The second revised edition was published in 2000 [3] with an update in 2003, and the 3rd edition was published in 2007 [4]. Several studies have reported the impact of implementation of guidelines-based management protocols for severe TBI on patient's treatment and outcome [5,6]. These studies have clearly demonstrated that the implementation of protocols for the management of severe TBI, incorporating recommendations from the guidelines, is associated with substantially better outcomes such as mortality rate, functional outcome scores, length of hospital stay, and costs [7,8]. However, there is still considerable and wide institutional variation in the care of patients with severe TBI.In general, TBI is divided into two discrete periods: primary and secondary brain injury. The primary brain injury is the physical damage to parenchyma (tissue, vessels) that occurs during traumatic event, resulting in shearing and compression of the surrounding brain tissue. The secondary brain injury is the result of a complex process, following and complicating the primary brain injury in the ensuing hours and days. Numerous secondary brain insults, both intracranial and extracranial or systemic, may complicate the primarily injured brain and result in secondary brain injury. Secondary, intracranial brain insults include cerebral edema, hematomas, hydrocephalus, intracranial hypertension, vasospasm, metabolic derangement, e

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