The American College of Surgeons (ACS) released comprehensive updated guidelines for managing traumatic brain injury, emphasizing both acute care protocols and long-term follow-up.

Early Intervention Protocols

The guidelines establish VTE prophylaxis initiation within 24 hours for low-risk nonoperative traumatic brain injury (TBI) patients, and 24-48 hours for moderate/high-risk cases, following stable CT findings. ICP monitoring is indicated for comatose patients (GCS ≤ 8) with structural damage on initial CT, with a threshold of 22 mm Hg and a 20-25 mm Hg range for higher-risk interventions.

New Biomarker Screening

For adults ≥18 years with suspected mild TBI, the guidelines introduce validated blood-based biomarkers GFAP and UCH-L1. Normal values are established as GFAP < 30 pg/mL and UCH-L1 < 360 pg/mL, potentially eliminating unnecessary CT scans.

Tiered Treatment Approach

The guidelines present a comprehensive three-tiered approach for managing intracranial hypertension:

• Tier One: CSF drainage, hyperosmolar therapy, maintaining CPP 60-70 mmHg, analgesia, and sedation.
• Tier Two: Mild hypocapnia, neuromuscular paralysis, and MAP challenge for autoregulation assessment.
• Tier Three: Barbiturate coma, decompressive craniectomy, and mild hypothermia (35-36°C).

Anticoagulation Management

Detailed reversal strategies are provided for patients on anticoagulants requiring emergency surgery, including specific protocols for different anticoagulant medications.

Rehabilitation Focus

Early rehabilitation should begin within 48 hours when neurosurgical, hemodynamic, and respiratory stability are achieved. Physical medicine and rehabilitation physicians are designated as key members of the primary trauma team from admission.

Geriatric Care

The guidelines incorporate frailty assessment protocols and expanded blunt cerebrovascular injury screening recommendations for older adults, acknowledging their unique risk factors and care needs.

Post-Acute Care

The guidelines emphasize treating TBI as both an acute and a chronic condition, establishing requirements for post-acute care follow-up systems and long-term monitoring.

The updated guidelines resulted from expert consensus and systematic evidence review by international multidisciplinary panels including neurosurgery, critical care, rehabilitation medicine, and related specialties.