Anaesthesia for Head Injury
Traumatic brain injury (TBI) affects 700 per 100,000 population annually in Australia, with anaesthetic management focused on preventing secondary brain injury by optimizing cerebral oxygenation and perfusion....
What matters first
Traumatic brain injury (TBI) affects 700 per 100,000 population annually in Australia, with anaesthetic management focused on preventing secondary brain injury by optimizing cerebral oxygenation and perfusion....
Rising ICP with Cushing triad (hypertension, bradycardia, irregular respiration)
2 Feb 2026
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Clinical board
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Urgent signals
Safety-critical features pulled from the topic metadata.
- Rising ICP with Cushing triad (hypertension, bradycardia, irregular respiration)
- Dilated fixed pupil suggesting uncal herniation
- GCS deterioration >2 points
- Acute extradural or subdural haematoma requiring emergent evacuation
Exam focus
Current exam surfaces linked to this topic.
- ANZCA Final Written
- ANZCA Final Clinical Viva
Content status and exam context
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Clinical explanation and evidence
Quick Answer
Traumatic brain injury (TBI) affects 700 per 100,000 population annually in Australia, with anaesthetic management focused on preventing secondary brain injury by optimizing cerebral oxygenation and perfusion. Pathophysiology: Primary injury (irreversible cellular damage at impact), secondary injury (hypotension, hypoxia, hypercapnia, hyperglycaemia, seizures causing additional damage). Intracranial pressure (ICP): Normal <15 mmHg, target <20-22 mmHg; Monro-Kellie doctrine requires reducing one component (CSF, blood, brain tissue) if another expands (haematoma, oedema). Cerebral perfusion pressure (CPP): MAP - ICP (or CVP), target 60-70 mmHg (avoid <50 or >70 initially); hypertension dangerous (increases cerebral oedema), hypotension dangerous (cerebral ischaemia). GCS assessment: Eye (1-4), Verbal (1-5), Motor (1-6); total 3-15; severe TBI GCS ≤8 (intubate for airway protection), moderate 9-12, mild 13-15. Anaesthetic goals: Avoid hypotension (SBP >90 mmHg), avoid hypoxia (SpO₂ >90%, PaO₂ >60 mmHg), avoid hypercapnia (PaCO₂ 35-40 mmHg, mild hyperventilation 30-35 only if acute herniation), maintain normoglycaemia (6-10 mmol/L), prevent seizures (phenytoin 15-20 mg/kg if severe), head elevation 30° (improves venous drainage). Induction: RSI with thiopental/propofol, fentanyl (avoid ketamine in severe TBI—traditionally contraindicated, but evidence may support safety), rocuronium; avoid succinylcholine if open eye injury or burns >24 hours old. Maintenance: Propofol or volatile <1 MAC (preserve cerebral autoregulation), remifentanil infusion, titrate to BIS 40-50; mannitol 0.25-1 g/kg for acute ICP elevation; hypertonic saline 3% 250 mL for refractory oedema; ventriculostomy for CSF drainage if available. Monitoring: ICP monitor (ventricular catheter or parenchymal probe) if severe TBI, CPP calculation, jugular venous saturation (SjO₂ 55-75%), brain tissue oxygen (PbtO₂). Emergence: Smooth emergence avoiding coughing/straining (raises ICP), ensure adequate analgesia and sedation in ICU. Indigenous patients: Higher TBI rates from motor vehicle accidents and violence; cultural considerations for family communication and end-of-life decisions. [1-10]