The management of patients with moderate and severe traumatic brain injury (TBI) is centred on the intensive care management to limit the extent of secondary injury to the brain, following the primary trauma. This management aims to optimise the homeostatic environment of the brain after injury and can be guided by multi-modality monitoring, including intracranial pressure (ICP) monitoring. This management often follows a tiered approach to introducing more aggressive interventions to correct physiology, based on evidence for ongoing secondary injury, such as raised ICP. The balance between risk and benefit for these interventions for individual patients is difficult, particularly in the absence of high quality randomised trials for many interventions in this area. In this Element, the authors outline both the approach to intensive care management of moderate and severe TBI, as well as the evidence base available for the interventions discussed.