Contemporary Medical Management of Traumatic Brain Injury: High-Income Countries

The past 30 years have seen the medical management of severe traumatic brain injury (TBI) evolve considerably, and this is in no small part to an increasing awareness of the complex response to trauma within the central nervous system and the extremely heterogeneous nature of the disease process. Recognition of issues has prompted a huge amount of research into potential neuroprotective therapies and has also led to the development and refinement of advanced multimodal neuromonitoring. Notwithstanding these technical advances, clinicians are still bound by a doctrine first described over 200 years ago. An appreciation of the Monro-Kellie doctrine is important to understand why certain therapies that previously formed the cornerstone of TBI management are used less frequently. Patients are no longer routinely hyperventilated, and those that develop intracranial hypertension are less likely to be placed in a barbiturate coma or rendered hypothermic. The current management of severe traumatic brain injury in high-income countries relies increasingly on information gained from complex multimodal monitoring and a stepwise introduction of therapies based on tiers of complexity, recognizing that increasingly aggressive medical therapies bring with them the potential for increasingly significant morbidity.