Neuro
Management of Severe Head Injury
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Management of Severe Head Injury
, Severe Head Injury, Severe Head Trauma
See Also
Severe Head Trauma Related Increased Intracranial Pressure
Head Injury
Cerebral Herniation
Management of Mild Head Injury
Management of Moderate Head Injury
Indications
Glasgow Coma Scale
(GCS) <= 8 (
Coma
)
Evaluation
See
Head Injury
Primary Survey
(ABCDE)
Secondary Survey
AMPLE History
Neurologic Exam
Glasgow Coma Scale
Pupil
lary light reaction
Oculocephalic (
Doll's Eyes
): if no
Spinal Injury
Oculovestibular Testing
Diagnostics
Testing in Unknown Injury
Head Evaluation
CT Head
in all patients
Air ventriculogram
Cerebral Angiogram
Spinal cord evaluation
CT
Cervical Spine
in most (if not all) patients
Abdominal Evaluation
If Systolic
Blood Pressure
<100 mmHg
CT Abdomen
or
Diagnostic Peritoneal Lavage
Abdominal Ultrasound
Exploratory Laparotomy/Celiotomy as needed
If Systolic
Blood Pressure
>100 mmHg
Dilated, non-reactive pupils,
Unilateral Weakness
Immediate
CT Head
CT Abdomen
or
Diagnostic Peritoneal Lavage
No focal or pupil changes
CT Abdomen
at time of
Head CT
Labs
Coagulation Studies (INR, PTT) as indicated
Urine Drug Screen
Blood
Alcohol
Level
Imaging
Head CT
C-Spine CT
Other imaging as indicated as part of
Trauma Evaluation
Management
Gene
ral
See
Severe Head Trauma Related Increased Intracranial Pressure
Document serial
Neurologic Exam
(especially before intubation)
Use short-acting
Sedative
s and paralytics
Avoid
Systemic Corticosteroid
s (increases mortality)
Roberts (2004) Lancet 364:1321-8 [PubMed]
Anticoagulant
s are associated with a much higher risk of
Intracranial Hemorrhage
Warfarin
is associated with delayed
Hemorrhage
Exercise
caution and close observation
Glucose
management
Avoid
Hypoglycemia
or
Hyperglycemia
Management
Increased Intracranial Pressure
See
Severe Head Trauma Related Increased Intracranial Pressure
Link includes key Severe Head Injury management
Management
Seizure
s
Observe for non-convulsive
Status Epilepticus
Observe for fine extremity
Tremor
or recurrent facial tics
Acute
Seizure
control
See
Status Epilepticus
Start with
Benzodiazepine
s (e.g.
Diazepam
,
Lorazepam
)
Seizure Prophylaxis
(esp. for
Intracranial Bleeding
)
No benefit in children if no immediate
Seizure
Young (2004) Ann Emerg Med 43:435-46 [PubMed]
Agents
Levetiracetam
(
Keppra
)
Mixed data on outcomes, but easier than other agents to dose with less level monitoring
Phenobarbital
Phenytoin
Management
Hypotension
Hypotension
is a concerning finding in the face of severe
Closed Head Injury
Most patients with significant
Closed Head Injury
are hypertensive
Identify
Hypotension
causes
Trauma
with occult
Hemorrhage
Neurogenic Shock
related to
Spinal Injury
Excessive mannitol infusion
Sedative
s (or RSI induction agents)
Subarachnoid Hemorrhage
Brainstem Herniation
Cardiogenic Shock
Hypotension
management
Correct
Hypotension
rapidly (especially in first 24 hours)
Target Mean Arterial Pressure (MAP) >80 mmHg and systolic
Blood Pressure
>100-110 mmHg
Maintain adequate
Cerebral Perfusion Pressure
(MAP - ICP)
Options
Vasopressor
s (first-line)
Hypertonic Saline
3%
Sodium Bicarbonate
1-2 ampules each over 5 minutes
References
Orman and Weingart in Herbert (2016) EM:Rap 16(12): 7-8
References
DeBlieux in Herbert (2016) EM:Rap 16(5): 8-10
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