الفهرس 
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Abstract
Traumatic brain injury (TBI) is the ‘silent epidemic’ of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide. The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation (1). Each year an estimated 69 million individuals will suffer a TBI, the vast majority of which will be mild (81%) and moderate (11%) in severity, the highest annual incidence of all-cause TBI is observed in the AMR-US/Can and Europe (1299 and 1012 cases per 100,000 people, respectively) (8). TBI is a complex dynamic process that initiates a multitude of cascades of pathological cellular pathways. Neurochemical changes associated with TBI including neurotransmitter-mediated activation of receptors and subsequent controlled ionic changes in the postsynaptic membranes of neurotransmitter-releasing cells and Post-TBI energy crisis and role of oxygen free radicals play important role in early detection of injury and prevention of secondary brain insult
Traumatic brain injuries assessment can be carried out clinically and radiologically
Clinically: In the setting of trauma, a neurologic examination is focused on identifying and assessing the function vital portions of the central nervous system. The exam primarily focuses on testing the patient’s mental status, conscious level, sensory exam, motor exam, and reflexes through applied scales ex (GCS, GCS-P, AVPU, SMS, AIS, Marshall CT scoring system) (17)
Radiological: by advanced neuroimaging ex (FMRI, MR Spectroscopy, Perfusion imaging). (27)
Multimodal Monitoring Systems integrates neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances. The aim of multimodality monitoring is to understand the complexity of the changes that lead to secondary brain injury Multimodal Monitoring Systems include invasive and noninvasive ICP assessment ,brain oxygenation status through SjVO2 Monitoring and microdialysis, EEG (4).
Neuroprotective strategy have been recently well involved in critical care management of traumatic brain injury patients to control mortalities and to improve outcome. Neuroprotective strategy can be classified to pharmacological and non-pharmacological methods ,Pharmacological ex (erythropoietin, statins, progesterone, Thyrotropin releasing hormone, cyclosporin A, substance p, magnesium sulphate).Non pharmacological methods like protective hypothermia (63).
Traumatic brain injury management 2020guidelines approved;
Early assessment of risk factors (age, mechanism of injury, duration of loss of consciousness, previous use of anticoagulation) still affecting the outcome and TBI mortality. Gcs score still the gold standard tool of early assessment .non contrast CT scan is the first recommended diagnostic radiological tool. The pregnant and pediatrics should also undergone CT brain without any delay. Early (A B C ) resuscitation efforts is the corner stone during the first few hours post TBI to prevent the secondary brain insults. Targeting systolic BP= 110-180 mm/hg, temp = 35-37°C, End tidal CO2 35-45 mm Hg, Glucose 3.5-7.7mmol/L, Hemoglobin >90 g/L, INR < 1.4, Na 135-160 mmol/L.
Nutrition care can either assist or complicate recovery. Clinical nutrition science is evolving as further evidence of care is tied to outcomes, incidence of complications, and the length of stay in the intensive care unit (ICU). The metabolic response to major trauma is marked by hypercatabolism.In the absence of exogenous provision of substrates, amino acids are “auto cannibalized” from endogenous sources. Initially, skeletal muscle proteolysis is followed by erosion of visceral structural elements and circulating proteins. The resultant acute protein malnutrition is associated with cardiac, pulmonary, hepatic, gastrointestinal, and immunologic dysfunctions. The goal of providing adequate nutrition support in TBI patients is to meet the needs of the hyper metabolic demands and minimize the loss of lean body mass. As with all critically ill patients, indirect calorimetry is the preferred method for determining energy requirements for TBI patients(88).
The intense catabolic response immediately after a critical neurological injury is well documented. Effective nutrition support can play a major role in attenuating the catabolic response and avoiding the potentially harmful effects of prolonged hyper metabolism. Glutamine, choline, branched chain amino acids and anti-oxidant play major role in attenuating secondary brain insults and improving outcome.(111) (112).