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Head Injury
Aka: Head Injury, Head Trauma, Closed Head Injury, Craniocerebral Trauma, Traumatic Brain Injury
- See Also
- Severe Head Injury
- Moderate Head Injury
- Mild Head Injury
- Concussion in Sports
- Postconcussion Syndrome
- Epidemiology
- Incidence: 1.7 Million Traumatic brain injuries in U.S. per year
- Minor Head Injury in 75% of cases
- Hospitalizations: 275,000
- Deaths: 52,000
- Pathophysiology
- Intracranial Pressure (ICP) association with injury
- Note measurements are in mmHg, not cmH2O
- Normal: 10 mmHg ICP
- Abnormal: 20 mmHg ICP
- Severe: 40 mmHg ICP
- Herniation: 50 mmHg ICP
- Cushing's Response
- Hypertensive response in face of increased ICP
- Helps maintain cerebral perfusion
- Do not use antihypertensives to lower Blood Pressure
- Results in decreased brain perfusion
- Exception: Intracranial Bleeding (e.g. aneurysmal bleeding)
- Precautions: Cardiopulmonary status in Head Injury
- Target PaO2: 200-300 mmHg
- PaO2 <200 mmHg and PaO2 >300 mmHg are both associated with higher mortality
- Option 1: Wean FIO2 to 50%, but still maintain O2Sat at 99-100% or
- Option 2:
- Wean oxygen to point that O2Sat starts to drop below 99-100% and
- Then increase the delivered oxygen by 2-4 L/min above that level
- Avoid Hyperventilation following intubation
- Hyperventilation is associated with worse outcomes in Traumatic Brain Injury
- Monitor End-Tidal CO2 or capnometer following intubation
- Maintain pCO2 at 35-40 mmHg (avoid pCO2 <25 mmHg)
- Maintain Respiratory Rate at 10-12 breaths per minute
- Avoid Hypotension
- Maintain systolic Blood Pressure >=100-110 mmHg (ATLS-10)
- References
- Majoewsky (2012) EM:RAP 12(5): 1-2
- Davis (2009) J Neurotrauma 26(12): 2217-23 [PubMed]
- Evaluation: General
- Systematic evaluation (unless isolated Minor Head Injury)
- See Trauma Evaluation (includes Primary Survey)
- See Secondary Trauma Evaluation
- Glasgow Coma Scale (GCS)
- First GCS at the initial emergency Trauma Evaluation is the best indicator of outcome at one year
- Goal in Trauma is to optimize care and allow the best chance for recovery to the initial GCS
- Pupil exam
- Neurologic Exam
- Motor Exam
- Sensory Exam
- Reflex Exam
- Alcohol or drug intake history
- Vital Signs
- Hypertension is typical response (see Cushing's Response above)
- Hypotension seen in pediatric Closed Head Injury
- Patrick (2002) Am J Surg 184:555-60 [PubMed]
- Signs Skull Fracture
- See Skull Fracture
- Vault Skull Fracture
- Basilar Skull Fracture
- CSF Rhinorrhea or Otorrhea
- Hemotympanum
- Post-auricular Bruising (Battle's Sign)
- Orbital Bruising (Raccoon's Eyes)
- CN VII palsy (Bell's Palsy)
- Signs Intracranial Injury
- Focal
- Epidural Hemorrhage
- Subdural Hemorrhage
- Intracerebral Hemorrhage
- Diffuse
- Mild Concussion
- Classic Concussion
- Diffuse Axonal Injury
- Scalp Lacerations with Hemorrhage
- Risk of significant blood loss to the point of Hemorrhagic Shock (especially children)
- Apply direct pressure to prevent further bleeding
- Close bleeding scalp lesions quickly (even temporarily) with Sutures, staples or Raney Clips
- Carefully investigate Laceration for associated complications prior to final closure
- Skull Fracture (deformity, bony fragments, CSF leakage)
- Subgaleal Hemorrhage may appear similar to Skull Fracture with deformity at the floor of the Laceration
- Evaluation: Age under 2 years
- See Head Injury CT Indications in Children
- Red Flags suggestive of serious injury
- Skull Fracture
- Scalp swelling (80-100% of Skull Fracture)
- Younger the age, the greater the risk
- Non-accidental Trauma (Child Abuse)
- No clear history of Trauma
- Symptoms that do not predict serious Head Injury
- Loss of consciousness
- Vomiting
- References
- Dachs (2012) AAFP Board Review Express, San Jose
- Imaging: Head and Neck
- CT Head
- Obtain in all cases of moderate or Severe Head Injury
- C-Spine imaging indications
- Brain injury is associated with Spinal Injury in 5% of cases
- See Cervical Spine Imaging in Acute Traumatic Injury
- See NEXUS Criteria
- Mild Head Injury Imaging Indications
- See Head Injury CT Indications in Adults
- See Head Injury CT Indications in Children
- Consider Head MRI in children in place of Head CT (due to radiation risk)
- Coagulopathy or oral Anticoagulant (e.g. Warfarin, Plavix)
- Approach based on evidence below
- Consider imaging all patients on Anticoagulants regardless of Head Injury severity
- Consider repeat CT Head imaging at 24 hours for patients on Warfarin regardless of signs or symptoms
- Consider 24 hour observation and repeat CT Head for elderly patients or those with INR >3
- Newman in Herbert (2014) EM:Rap 14(1): 6
- Even Minor Head Injury on oral Anticoagulants is associated with significant bleeding risk (often without red flags)
- Clopidogrel was associated with an initial 12% CNS HemorrhageIncidence, but no delayed bleeding
- Warfarin was associated with an initial 6% CNS HemorrhageIncidence with 0.6% having delayed bleeding
- Nishijima (2012) Ann Emerg Med 59(6): 460-8 [PubMed]
- Warfarin is associated with delayed Intracranial Bleeding
- One study demonstrated 6% of patients at 24 hours
- Bleeding may be delayed as long as 1 week after Head Injury
- Most patients with CNS Hemorrhage on Warfarin had GCS 14-15 and no focal neurologic changes
- Menditto (2012) Ann Emerg Med 59(6): 451-5 [PubMed]
- Other studies demonstrated a 0.4 to 1.4% risk of delayed Intracranial Hemorrhage
- In these studies, delayed head bleeding required neurosurgical intervention is rare
- Lim (2016) Am J Emerg Med 34(1): 75-8 +PMID: 26458530 [PubMed]
- Campiglio (2017) Neurol Clin Pract 7(4): 296-305 +PMID: 29185534 [PubMed]
- Repeat Head CT protocol
- Repeat Head CT in 6-12 hours unless criteria below are met
- Most patients are observed in hospital while awaiting repeat Head CT
- Repeat Head CT not needed in minor Head Trauma if all of following criteria met (expert opinion)
- Initial Head CT negative (including no Skull Fracture and no Soft Tissue Injury) AND
- INR <2.5 AND
- Age < 65 years old AND
- Glasgow Coma Scale 15 AND
- Non-focal exam AND
- No persistent Emesis
- Associated Conditions
- See Altered Level of Consciousness
- See Coma
- Brain Contusion
- Concussion
- Basilar Skull Fracture
- Epidural Hematoma
- Subdural Hematoma
- Subarachnoid Hemorrhage
- Seizure Disorder
- Increased Intracranial Pressure
- Diffuse Axonal Injury
- Management
- See Management of Mild Head Injury (GCS 13-15 at two hours)
- See Concussion (mildest subset of Mild Traumatic Brain Injury)
- See Management of Moderate Head Injury (GCS 9-12 at two hours)
- See Management of Severe Head Injury (GCS 3-8 at two hours)
- Avoid Systemic Corticosteroids (increases mortality)
- Roberts (2004) Lancet 364:1321-8 [PubMed]
- Avoid Progesterone (does not improve outcomes in TBI)
- Wright (2014) N Engl J Med 371(26): 2457-66 +PMID:25493974 [PubMed]
- Skolnick (2014) N Engl J Med 371(26): 2467-76 +PMID:25493978 [PubMed]
- References
- (2012) ATLS, ACOS, Chicago, p. 149-73