Traumatic brain injury (TBI) can be pathophysiologically classified into either primary or secondary injury. It is an important resuscitation to prevent the secondary injury which includes hypoxia, hypotension, cerebral ischemia, and intracranial hypertension, in the acute management of patients with severe TBI. However, many aspects of the proper management are controversial. The authors focused on the management of the secondary brain injury after TBI and categorized the acute care of the patients with severe TBI as generalized management and management of the intracranial hypertension. They reviewed the pertinent literatures using evidence-based approach and showed practical recommendations for each items. With knowledge of this evidence-based management, appropriate management with better outcome may be accomplished in acute staged TBI.