Neuroprotection at the Bedside: A Sequenced, Tier-Based Operational Strategy for Severe Acute Brain Injury

Abstract

Guidance for severe acute brain injury is distributed across a dozen documents written for different purposes and updated on different cycles. The clinician at the bedside at 03:00 needs one sequence, in order, with numbers.
This review assembles current evidence into a single operational strategy organised the way care is actually delivered: what to do in the first hour, what runs continuously for every patient regardless of intracranial pressure, what to monitor and when to place it, what the targets are, how to escalate through tiers when those targets fail, how to manage the parallel problems that arrive alongside intracranial hypertension, where non-traumatic injury demands a different answer, how to come back down, and when to stop.
Recommendations are drawn from the Brain Trauma Foundation guidelines (fourth edition with the 2020 decompressive craniectomy update; a fifth edition remains in preparation and unpublished), the Seattle International Severe Traumatic Brain Injury Consensus Conference tiered algorithms for management with intracranial pressure monitoring and with combined pressure and brain oxygen monitoring, the CREVICE protocol for settings without invasive monitoring, the 2026 Brain Trauma Foundation penetrating injury guidelines, and current pain, sedation, seizure, transfusion, and ventilation evidence. Every threshold is given with its evidentiary strength, and areas of genuine uncertainty — transfusion thresholds, brain tissue oxygen targets, decompressive craniectomy selection, autonomic prophylaxis — are marked as contested rather than resolved