Abdalrahman MNAA, Elhadidi AEA, Alkhani RAK, et al. Neuroprotection at the Bedside: A Sequenced, Tier-Based Operational Strategy for Severe Acute Brain Injury. Natural Resources for Human Health 2026; 6(21s): 812–823.
Guidance for severe acute brain injury is spread 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 paper puts current evidence into a single operational strategy, organised the way care is actually delivered.
Three rules
- Sequence beats intensity. Most preventable secondary injury comes from doing the right things in the wrong order: sedation before analgesia, CSF drainage before head position, hyperventilation before checking whether the tube tie is obstructing venous outflow.
- The floor is not optional. The baseline measures apply to every patient at every hour, whether or not intracranial pressure is monitored. Failures there cause more harm than failures at the top of the ladder, and nothing alarms when they happen.
- Every escalation needs an exit. Nothing in the higher tiers starts without a stated condition for stopping it.
What the paper covers
- Scope, audience and methods
- Hour zero: the first sixty minutes
- Penetrating injury
- The floor: continuous measures for every patient
- Monitoring: what to place, and when
- Targets
- Tiered escalation for intracranial hypertension
- Hyperventilation and its own rules
- The parallel problems
- Coming back down
- Where non-traumatic injury diverges
- Prognostication and goals of care
- A daily neuroprotection checklist
- Limitations and evidence status
Sources it draws on
The Brain Trauma Foundation guidelines (fourth edition, with the 2020 decompressive craniectomy update), the Seattle International Severe Traumatic Brain Injury Consensus Conference 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 evidence on pain, sedation, seizures, transfusion and ventilation. Every threshold carries its strength of evidence, and the genuinely uncertain areas — transfusion thresholds, brain tissue oxygen targets, selection for decompressive craniectomy, autonomic prophylaxis — are marked as contested rather than resolved.
Who it is for
Intensivists, neurologists, neurosurgeons, emergency physicians and senior nursing staff caring for adults with severe acute brain injury, in units with and without invasive neuromonitoring. It is a narrative synthesis, not a systematic review, and its protocols have not been prospectively evaluated.