Traumatic Brain Injury (TBI) Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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TBI classification, primary vs secondary injury, ICP monitoring and management, herniation recognition, osmotherapy, and ICU nursing management of the severe TBI patient.
1. TBI Classification
| Severity | GCS Score | LOC | Post-Traumatic Amnesia |
|---|
| Mild (concussion) | 13–15 | 0–30 minutes | <24 hours |
| Moderate | 9–12 | 30 min–24 hr | 1–7 days |
| Severe | ≤8 | >24 hours | >7 days |
2. Primary vs Secondary Brain Injury
Primary injury: Direct mechanical damage at moment of trauma — contusion, laceration, diffuse axonal injury (DAI), hemorrhage. Cannot be reversed — focus on prevention.
Secondary injury: Progressive neurological damage in the hours/days after TBI — from hypoxia, hypotension, hyperthermia, elevated ICP, seizures, coagulopathy, metabolic derangements. This is what nurses prevent.
The "Golden Hour" of TBI: The most important nursing intervention is preventing secondary brain injury:
- Avoid hypotension (SBP <90 = doubles mortality)
- Avoid hypoxia (SpO2 <90 = doubles mortality)
- Avoid hyperthermia (fever worsens metabolic demand)
- Avoid hypoglycemia and hyperglycemia
- Maintain CPP 60–70 mmHg
3. Types of Intracranial Hemorrhage
| Type | CT Appearance | Classic Presentation | Treatment |
|---|
| Epidural Hematoma (EDH) | Biconvex (lens-shaped) hyperdense collection; does not cross suture lines | Lucid interval — brief LOC, then awakens, then rapid neurological decline (arterial bleed = middle meningeal artery) | Surgical evacuation (neurosurgical emergency) |
| Subdural Hematoma (SDH) | Crescent-shaped hyperdense (acute) or hypodense (chronic) collection; crosses suture lines | Acute: immediate LOC + rapid decline (venous bleed). Chronic: elderly, on anticoagulation, falls — weeks of gradually worsening headache, cognitive change | Surgical burr holes or craniotomy for acute; observation or burr holes for chronic |
| Intracerebral Hemorrhage (ICH) | Hyperdense (bright white) within brain parenchyma | Depends on location; sudden focal neurological deficit + headache | Blood pressure control; reversal of anticoagulation; selected surgical cases |
| Subarachnoid Hemorrhage (SAH) | Blood in subarachnoid space; "star pattern" or filled cisterns | Thunderclap headache; "worst headache of my life" | Nimodipine; secure aneurysm; EVD if hydrocephalus |
| Diffuse Axonal Injury (DAI) | May be normal or show microhemorrhages at white matter junctions | Immediate coma; no lucid interval; often from high-speed deceleration (MVA) | No specific treatment; supportive; poor prognosis |
4. ICP Monitoring
Indications for ICP Monitor
- Severe TBI (GCS ≤8) with abnormal CT (hemorrhage, edema, herniation)
- Severe TBI with normal CT but ≥2 risk factors: age >40, unilateral or bilateral posturing, SBP <90
ICP Monitor Types
| Type | Location | Advantage | Disadvantage |
|---|
| External Ventricular Drain (EVD) — Gold Standard | Lateral ventricle via burr hole | Therapeutic (CSF drainage) + ICP measurement; can recalibrate | Infection risk (ventriculitis); cannot be repositioned easily |
| Intraparenchymal monitor (Camino, Licox) | Brain parenchyma | Lower infection risk; easier placement | Cannot drain CSF; cannot recalibrate (zero drift) |
ICP and CPP Targets in TBI
- ICP target: <20–22 mmHg
- CPP = MAP − ICP; target CPP 60–70 mmHg
- If ICP >20 mmHg sustained → treat (see protocol below)
- Normal ICP: 5–15 mmHg
5. EVD (External Ventricular Drain) Nursing Care
EVD Management Essentials:
- Level the transducer to the tragus of the ear (external auditory meatus = foramen of Monro level)
- Zero at insertion and with any patient or equipment repositioning
- Set drip chamber height per order (cm H2O above the reference level — allows CSF to drain when ICP exceeds this threshold)
- Document: ICP waveform (normal = pulsatile; loss of pulsatility = kinked or clotted catheter or ventricular collapse), CSF drainage (color, amount, character), drain open vs closed
- Normal CSF: clear, colorless; 10–20 mL/hr drainage maximum in most protocols
- Turbid or bloody CSF: notify provider (ventriculitis, hemorrhage)
- Clamp drain during transport or patient turns (prevents overdrainage → pneumocephalus, hemorrhage)
- Strict aseptic technique for any manipulation; dressing changes per protocol
EVD overdrainage: Too much CSF drained too fast → pneumocephalus (air enters), transtentorial herniation from pressure gradient, hemorrhage. Ensure drain height is set correctly. If patient has sudden worsening after EVD manipulation — clamp drain and notify provider STAT.
6. ICP Management Protocol (Stepwise)
Tier 1 (all severe TBI patients):
- HOB 30° in neutral alignment (no neck flexion, rotation)
- Avoid Valsalva: stool softeners, limit suctioning (pretreat with lidocaine IV if repeated suctioning needed)
- Sedation and analgesia: fentanyl + propofol or midazolam
- Normothermia: treat fever aggressively (acetaminophen, cooling blankets)
- Normoglycemia: target BG 140–180 mg/dL
- Prevent seizures: levetiracetam × 7 days post-TBI
- Euvolemia: avoid dehydration; target euvolemic to slightly hypervolemic
- Maintain CPP ≥60 mmHg: vasopressors (norepinephrine) to raise MAP if CPP is low
Tier 2 (ICP persistently >20 despite Tier 1):
- CSF drainage via EVD (if in place)
- Osmotherapy: Mannitol 0.25–1 g/kg IV bolus (causes osmotic diuresis; monitor serum osmolality — hold if >320 mOsm/kg) OR 3% hypertonic saline bolus 250 mL or 30 mL of 23.4% NaCl
- Deeper sedation (barbiturate coma with pentobarbital — requires EEG monitoring for burst suppression)
Tier 3 (refractory ICP >25 despite Tier 2):
- Decompressive craniectomy (remove portion of skull to allow brain to swell)
- Therapeutic hypothermia (controversial — evidence limited)
- Bilateral decompression
Hyperventilation in TBI
Hyperventilation in TBI — used ONLY as a bridge: Lowering PaCO2 causes cerebral vasoconstriction → reduces CBF → reduces ICP. Target PaCO2 30–35 mmHg for herniation. Do NOT hyperventilate prophylactically or chronically (reduces CBF → ischemia). Use ONLY as temporizing measure for acute herniation while definitive treatment is arranged.
7. Herniation Syndromes
| Herniation Type | What Herniates | Signs |
|---|
| Uncal (transtentorial) | Medial temporal lobe (uncus) through tentorium | Ipsilateral blown pupil (CN III compression) → bilateral blown pupils → decorticate → decerebrate → flaccid. Contralateral hemiplegia. |
| Central transtentorial | Diencephalon downward | Bilateral pinpoint pupils → midposition fixed → bilateral motor changes → coma |
| Tonsillar (downward) | Cerebellar tonsils through foramen magnum | Bradycardia, hypertension, respiratory arrest (brainstem compression) = TERMINAL |
8. Post-TBI Complications
- Post-traumatic seizures: Early (<7 days) — prevented with levetiracetam; late (>7 days) = post-traumatic epilepsy. Seizures dramatically worsen ICP.
- Diabetes insipidus (DI): Posterior pituitary injury → loss of ADH → massive dilute urine output (>250 mL/hr, specific gravity <1.005, serum Na rises). Treat with IV DDAVP (desmopressin).
- SIADH: Too much ADH → water retention → hyponatremia. Restrict fluids; monitor Na.
- Cerebral Salt Wasting (CSW): Excessive Na loss in urine → hypovolemic hyponatremia. Treat with IV NS or 3% NS + fluid resuscitation (opposite of SIADH management).
- DVT/PE: Immobility + hypercoagulable state. SCDs from day 1; pharmacologic prophylaxis when safe (usually 24–72 hr if hemorrhage stable on repeat imaging).
- Autonomic storming: Sympathetic surge — tachycardia, hypertension, diaphoresis, hyperthermia, posturing. Treat with propranolol, clonidine, opioids, bromocriptine.
NCLEX High-Yield TBI Points
- Epidural hematoma: lucid interval then rapid deterioration = middle meningeal artery = neurosurgical emergency
- Subdural hematoma: crosses suture lines; crescent-shaped on CT
- HOB position in TBI/ICP: 30 degrees, neutral alignment
- CPP = MAP − ICP; target ≥60–70 mmHg in TBI
- EVD transducer level: tragus of the ear
- Hyperventilation in TBI: only for acute herniation (temporary); target PaCO2 30–35 mmHg
- Mannitol: hold if serum osmolality >320 mOsm/kg
- Post-TBI DI: massive dilute urine (>250 mL/hr) + rising serum Na → DDAVP
- Avoid in TBI: hypotension (SBP <90) and hypoxia (SpO2 <90) — both double mortality
- Seizure prophylaxis in TBI: levetiracetam × 7 days (prevents early seizures)
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