The primary goal of management of the patient with severe traumatic brain injury (TBI) in the intensive care unit (ICU) is to prevent secondary brain injury. Management of TBI often begins with a decision to perform endotracheal intubation in the emergency room. Hypotension has most consistently been associated with poor neurologic outcome following severe TBI. Some physicians prefer to continue use of the semi-rigid collar until an adequate clinical examination, a flexion-extension X-ray or magnetic resonance image of the cervical spine can be obtained to exclude ligamentous and other soft tissue injury. Sedation and analgesia is of critical importance in the TBI patient, not only to permit safe and effective mechanical ventilation and avoid unintended tracheal extubation or line removal but also to adequately control intracranial pressure (ICP). The management of patients with TBI is often challenging but rewarding, with a significant number of patients achieving a long-term neurologic outcome.