The monitored brain — severe TBI in the ICU
| Patient | 24M, acute phase |
|---|---|
| Injurybilateral frontal contusions with diffuse axonal injury | |
| Severity | Worst GCS 8 |
| Days since injury | 3 |
| Before the injuryIndependent. Worked as an electrician; rode weekends. | |
| PrecautionsICP monitor — head-of-bed position per team parameters; Intubated — airway managed by nursing and respiratory therapy; Autonomic instability risk — heart rate and blood pressure watched through every position change | |
Test yourself
When does mobilization start for this patient?
The teaching
Severe TBI therapy in the ICU is physiology-first. The fourth-edition Brain Trauma Foundation guidelines set the intracranial treatment threshold the session is dosed against, and the disorders-of-consciousness guideline names the CRS-R as the instrument that separates vegetative from minimally conscious — the boundary the plan turns on. What you do with it: mobilize in graded steps the monitor proves tolerated, position for venous outflow with the neck neutral, and score consciousness with the instrument built for it rather than the one already in the chart.
- ICP sustained above the treatment threshold despite positioning and escalation
- A new pupillary asymmetry or a blown pupil — stop and call the team now
- Tachycardia, hypertension and posturing with handling — think sympathetic storming, not agitation
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Carney N et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017. Stocchetti N et al. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol. 2017 · Carney N et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017. Ng I, Lim J, Wong HB. Effects of head posture on cerebral hemodynamics. Neurosurgery. 2004 · Giacino JT et al. The JFK Coma Recovery Scale-Revised. Arch Phys Med Rehabil. 2004. Giacino JT et al. Practice guideline update summary: disorders of consciousness. Neurology. 2018