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| == Background ==
| | #REDIRECT[[Head trauma (main)]] |
| *Classification based on GCS
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| **14-15: Mild
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| **9-13: Moderate
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| **3-8: Severe
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| *B/l pinpoint pupils suggests opiate use or pontine lesion
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| *Pretreatment w/ lidocaine has not been shown to improve outcomes
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| *All pts on coumadin should have head CT performed
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| == Clinical Decision Rules ==
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| === NEXUS-II ===
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| *Consider no head CT if all of the following are negative:
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| **Abnormal alertness, behavior
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| **Suspected skull fracture
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| **Recurrent vomiting
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| **Age ≥65
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| **Coagulopathy
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| **Focal neuro deficit
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| **Scalp hematoma
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| == Diagnosis ==
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| *Monitor for increased ICP
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| **HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations
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| *Monitor for herniation
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| **Ipsilateral fixed and dilated pupil
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| **Contralateral motor paralysis
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| ===Skull Fracture===
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| *All skull fx require head CT
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| *ABX indicated for:
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| **Open fx
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| **Depressed fx
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| **Involves sinus
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| **Leads to pneumocephalus
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| *Vancomycin 1gm IV AND CTX 2gm IV
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| ===Cerebral Contusion / Intracerebral Hemorrhage===
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| *Often a/w SAH
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| *ICH can occur days after trauma often at site of resolving contusions
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| **More common in pts w/ coagulopathy
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| ===Subarachnoid Hemorrhage===
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| *Most common CT abnormality in moderate-severe TBI
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| *+Meningeal signs
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| *Associated with nonaccidental trauma in infants
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| ===Epidural Hematoma===
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| *Due to trauma to temporoparietal area w/ associated skull fx and meningeal artery damage
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| *Classic presentation of LOC > lucid interval > LOC only occurs in 20%
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| *Injury to brain is often absent so good recovery if hematoma evacuated in time
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| ===Subdural Hematoma===
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| *Often a/w underlying parenchymal damage
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| *More common in elderly, alcoholics, children <2yr
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| *May be acute (rapid LOC) or chronic (AMS w/ gradual decrease in consciousness)
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| == DDx ==
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| #DAI
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| #Contusion/intracerebral hematoma
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| #Epidural
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| #Subdural
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| #Traumatic SAH
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| #[[Concussion]] | |
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| ==Treatment==
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| ===Prevent further brain injury===
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| #Head of bed @ 30 degrees
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| #Prevent:
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| ##Hypotension
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| ##Hypoxia
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| ##Anemia
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| ##Hyperthermia
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| ##Coagulopathy
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| ===Increased ICP===
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| #Ensure adequate sedation (prevent gag reflex)
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| #IVF to goal MAP >80 (maintains cerebral perfusion)
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| #Mannitol
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| ##Consider as long as pt is not hypotensive
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| ##Reduces ICP w/in 30min; duration of action of 6-8hr
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| ##Bolus 0.25-1 gm/kg
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| ##Monitor I+O to maintain euvolemia
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| #Hyperventilation
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| ##No longer recommended as prophylactic intervention
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| ###Hyperventilation to PaCO2 <25 never indicated
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| ##Brief course only recommended if impending herniation (i.e., Cushing reflex)
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| ####Maintain PaCO2 30-35
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| #Seizure
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| ##Treat immediately
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| ##Seizure prophylaxis reduces sz but does not improve long-term outcome
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| == See Also ==
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| *[[Glasgow Coma Scale (GCS)]]
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| *[[Head Trauma (Minor) (Peds)]]
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| *[[Concussion]]
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| == Source ==
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| *Annals 2/09, Stein
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| *Tintinalli
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| [[Category:Trauma]]
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