The improvement in outcome from TBI over the past 20 years has not been due to any one major breakthrough. The reduction in mortality can be attributed to improved service organisation and delivery, including the improvement in general critical care management in this patient population.

3 Severe disability

4 Moderate disability

5 Good recovery

Management aspects of neuro-intensive care

• Keep sodium >140 mmol/L. A fall in serum sodium produces an osmotic gradient across the blood-brain barrier, and aggravates cerebral oedema

• Avoid hyperglycaemia (treat blood glucose >11 mmol/L). Hyperglycaemia may aggravate ischaemic brain injury by increasing cerebral lactic acidosis

• Feed via an orogastric tube. Gastric motility agents can be given as required

• Use TED stockings; avoid low dose heparin

• Apply 15-30° head up tilt with head kept in neutral position; may improve CPP

• No parenteral non-ionic fluid must be given.

Other guidelines available:

From Brain Trauma Foundation. Guidelines for the management of severe head injury. American Association of Neurological Surgeons. Chicago, IL, 1995. guidelines

Recommendations for the transfer of patients with acute head injuries to neurosurgical units. The Association of Anaesthetists of Great Britain and Ireland. London, 1996. ~nassoca

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