Emergency Medicine Book


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
  1. See Also
    1. Severe Head Trauma Related Increased Intracranial Pressure
    2. Head Injury
    3. Cerebral Herniation
    4. Management of Mild Head Injury
    5. Management of Moderate Head Injury
  2. Indications
    1. Glasgow Coma Scale (GCS) <= 8 (Coma)
  3. 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
  4. 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
  5. Labs
    1. Coagulation Studies (INR, PTT) as indicated
    2. Urine Drug Screen
    3. Blood Alcohol Level
  6. Imaging
    1. Head CT
    2. C-Spine CT
    3. Other imaging as indicated as part of Trauma Evaluation
  7. 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. Warfarin is associated with delayed Hemorrhage
      2. Exercise caution and close observation
    5. Glucose management
      1. Avoid Hypoglycemia or Hyperglycemia
  8. Management: Increased Intracranial Pressure
    1. See Severe Head Trauma Related Increased Intracranial Pressure
    2. Link includes key Severe Head Injury management
  9. Management: Seizures
    1. Observe for non-convulsive Status Epilepticus
      1. Observe for fine extremity Tremor or recurrent facial tics
    2. Acute Seizure control
      1. See Status Epilepticus
      2. Start with Benzodiazepines (e.g. Diazepam, Lorazepam)
    3. 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
  10. 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 and systolic Blood Pressure >100-110 mmHg
      3. Maintain adequate Cerebral Perfusion Pressure (MAP - ICP)
      4. Options
        1. Vasopressors (first-line)
        2. Hypertonic Saline 3%
        3. Sodium Bicarbonate 1-2 ampules each over 5 minutes
    4. References
      1. Orman and Weingart in Herbert (2016) EM:Rap 16(12): 7-8
  11. References
    1. DeBlieux in Herbert (2016) EM:Rap 16(5): 8-10

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