Written by Clay Smith
Spoon Feed
The Brain Trauma Foundation guidelines on penetrating traumatic brain injury (pTBI) offer helpful tips to improve survival.
U.S.—more guns than people. Deaths—132 people every day. Correlation?
The Brain Trauma Foundation (BTF) has guidelines for TBI, but pTBI is different. Here are the recommendations.
- In the prehospital and ED setting, follow standard BTF guidelines.
- These are commonsense: maintain oxygenation, avoid hypotension (or extreme hypertension), avoid hyperthermia (or hypothermia), aim for EtCO2 35-40, check pupils, calculate GCS after medically optimized and off paralytics, and transport to a trauma center.
- I would add to avoid neck constriction (optimize venous outflow), aggressively treat any seizure activity, and elevate the head of the bed 30 degrees if possible.
- Don’t use cervical collars for clear pTBI and no neck injury.
- Stop massive external hemorrhage (duh); transfuse if hemorrhagic shock.
- Be ready to pack massive oral bleeding.
- Imaging: Get a CTA. If in doubt or traumatic intracranial aneurysm (tICA) is found, send for formal angiography. Repeat CTA in 7–21 days is advised, as tICA development may be delayed.
- Intracranial pressure (ICP) monitoring is advised. Keep ICP under 22 cm H2O and cerebral perfusion pressure 60–70 mm Hg.
- Consider prophylactic antibiotics. Venous thromboembolism chemoprophylaxis is nuanced. Try to start in 48 hours if stable ICH volume and no need for urgent operation. Start anti-seizure prophylaxis for up to 7 days.
- Futility: see futility toolkit.
How will this change my practice?
Good trauma care is also good pTBI care. I will be getting CTA on all these patients now. The futility checklist is also quite helpful.
Having a front-row seat to gun violence makes me long for meaningful gun regulation. I own guns. I would gladly submit to any regulations, including giving them all away. I’ve had enough.
Source
Executive summary of the Brain Trauma Foundation Guidelines for the Management of Penetrating Traumatic Brain Injury, Second Edition. J Trauma Acute Care Surg. 2026 Mar 1;100(3):371-379. doi: 10.1097/TA.0000000000004868. Epub 2026 Jan 9. PMID: 41700745.
