Management of severe traumatic brain injury in the first 48 hours: A systems-based approach

Severe traumatic brain injury (TBI) presents significant challenges to clinical staff working in the critical care setting. Patients who have sustained a severe TBI require prompt diagnosis and referral, and timely assessment and intervention if secondary brain injury is to be minimized. This article reviews these aspects of care in the context of a patient case study, using an ABCDE (airway, breathing, circulation, disability, external examination) systems-based approach to assessment. Management of the patient in the pre-hospital phase, accident and emergency department and intensive care unit during the first 24–48 hours after injury is reviewed and analysed incorporating current recommendations and guidelines based on existing evidence. A discussion of the extent and limitations of the existing evidence base pertaining to this patient group is included, as well as an analysis of the strengths and weaknesses of care in TBI management. The physiological effects of TBI during the acute phase, and the patient's outcome, are discussed. Recommendations for future practice are made and the implications for future service organization and delivery considered.