Management of Severe Head Injury

Aka: Management of Severe Head Injury, Severe Head Injury, Severe Head Trauma, Severe Traumatic Brain Injury, Severe Closed Head Injury, Brain Injury Guidelines 3, BIG 3 Criteria in Traumatic Brain Injury

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II. Indications

  1. Glasgow Coma Scale (GCS) <= 8 (Coma)

III. Evaluation

  1. See Head Injury
  2. Primary Survey (ABCDE)
  3. Secondary Survey
  4. AMPLE History
  5. Neurologic Exam
    1. Glasgow Coma Scale
    2. Pupillary light reaction
    3. Oculocephalic (Doll's Eyes): if no Spinal Injury
    4. Oculovestibular Testing

IV. Diagnostics: Testing in Unknown Injury

  1. Head Evaluation
    1. CT Head in all patients
    2. Air ventriculogram
    3. Cerebral Angiogram
  2. Spinal cord evaluation
    1. CT Cervical Spine in most (if not all) patients
  3. Abdominal Evaluation
    1. If Systolic Blood Pressure <100 mmHg
      1. CT Abdomen or Diagnostic Peritoneal Lavage
      2. Abdominal Ultrasound
      3. Exploratory Laparotomy/Celiotomy as needed
    2. If Systolic Blood Pressure >100 mmHg
      1. Dilated, non-reactive pupils, Unilateral Weakness
        1. Immediate CT Head
        2. CT Abdomen or Diagnostic Peritoneal Lavage
      2. No focal or pupil changes
        1. CT Abdomen at time of Head CT

V. Labs

  1. Coagulation Studies (INR, PTT) as indicated
  2. Urine Drug Screen
  3. Blood Alcohol Level

VI. Imaging

  1. Head CT
  2. C-Spine CT
  3. Other imaging as indicated as part of Trauma Evaluation

VII. Diagnosis: Brain Injury Guidelines 3 (BIG 3) Criteria

  1. Severe Head Injury or High risk features
    1. Does not meet criteria for BIG 2 or BIG 1
    2. Requires Trauma Transfer, close monitoring, neurosurgical evaluation and serial Head CT
    3. Midline shift, mass effect or Herniation
    4. Depressed Skull Fractures
    5. Anticoagulation or antiplatelet use
    6. Large or high risk Hemorrhages
      1. Intraventricular Hemorrhage
      2. Subdural Hematoma or Epidural Hematoma >7 mm thick
      3. Single intraparenchymal Hemorrhage >7 mm (or IPH in >2 locations)
      4. Generalized Subarachnoid Hemorrhage
  2. References
    1. Joseph (2014) J Trauma Acute Care Surg 76(4):965-9 +PMID: 24662858 [PubMed]
    2. Joseph (2022) J Trauma Acute Care Surg 93(2):157-65 +PMID: 35343931 [PubMed]

VIII. Management: General

  1. See Severe Head Trauma Related Increased Intracranial Pressure
  2. Document serial Neurologic Exam (especially before intubation)
    1. Use short-acting Sedatives and paralytics
  3. Avoid Systemic Corticosteroids (increases mortality)
    1. Roberts (2004) Lancet 364:1321-8 [PubMed]
  4. Anticoagulants are associated with a much higher risk of Intracranial Hemorrhage
    1. See Emergent Reversal of Anticoagulation
    2. Warfarin is associated with delayed Hemorrhage
    3. Exercise caution and close observation
  5. Glucose management
    1. Avoid Hypoglycemia or Hyperglycemia

IX. Management: Intracranial Findings

  1. Increased Intracranial Pressure
    1. See Severe Head Trauma Related Increased Intracranial Pressure
    2. Link includes key Severe Head Injury management
  2. Intracranial Hemorrhage
    1. See Anticoagulant Reversal
    2. See Epidural Hematoma
    3. See Subdural Hematoma
    4. See Traumatic Intracerebral Hemorrhage
    5. See Traumatic Intracranial Subarachnoid Hemorrhage

X. Management: Seizures

  1. See Post-Traumatic Seizure
  2. Observe for non-convulsive Status Epilepticus
    1. Observe for fine extremity Tremor or recurrent facial tics
  3. Acute Seizure control
    1. See Status Epilepticus
    2. Start with Benzodiazepines (e.g. Diazepam, Lorazepam)
  4. Seizure Prophylaxis (esp. for Intracranial Bleeding)
    1. No benefit in children if no immediate Seizure
      1. Young (2004) Ann Emerg Med 43:435-46 [PubMed]
    2. Agents
      1. Levetiracetam (Keppra)
        1. Mixed data on outcomes, but easier than other agents to dose with less level monitoring
      2. Phenobarbital
      3. Phenytoin

XI. Management: Hypotension

  1. Hypotension is a concerning finding in the face of Severe Closed Head Injury
    1. Most patients with significant Closed Head Injury are hypertensive
  2. Identify Hypotension Causes
    1. Trauma with occult Hemorrhage
    2. Neurogenic Shock related to Spinal Injury
    3. Excessive Mannitol infusion
    4. Sedatives (or RSI induction agents)
    5. Subarachnoid Hemorrhage
    6. Brainstem Herniation
    7. Cardiogenic Shock
  3. Hypotension management
    1. Correct Hypotension rapidly (especially in first 24 hours)
    2. Target Mean Arterial Pressure (MAP) >80 mmHg
      1. Target systolic Blood Pressure >110 mmHg for ages 15 to 49 years, and age >70 years
      2. Target systolic Blood Pressure >100 mmHg for ages 50 to 69 years
    3. Maintain adequate Cerebral Perfusion Pressure (MAP - ICP)
    4. Primary medication management of Hypotension
      1. Normal Saline
      2. Vasopressors (refractory Hypotension)
    5. Other medical management
      1. Hypertonic Saline 3%
      2. Sodium Bicarbonate 1-2 ampules each over 5 minutes
  4. References
    1. Orman and Weingart in Herbert (2016) EM:Rap 16(12): 7-8

XII. References

  1. DeBlieux in Herbert (2016) EM:Rap 16(5): 8-10

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