Head trauma (adult)

Background

• Classification based on GCS
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe
• B/l pinpoint pupils suggests opiate use or pontine lesion
• Pretreatment w/ lidocaine has not been shown to improve outcomes
• All pts on coumadin should have head CT performed

Clinical Decision Rules

NEXUS-II

• Consider no head CT if all of the following are negative:
  • Abnormal alertness, behavior
  • Suspected skull fracture
  • Recurrent vomiting
  • Age ≥65
  • Coagulopathy
  • Focal neuro deficit
  • Scalp hematoma

Diagnosis

• Monitor for increased ICP
  • HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations
• Monitor for herniation
  • Ipsilateral fixed and dilated pupil
  • Contralateral motor paralysis

Skull Fracture

• All skull fx require Head CT
• ABX indicated for:
  • Open fx
  • Depressed fx
  • Involves sinus
  • Leads to pneumocephalus
• CTX 2gm IV + metronidazole 500mg +/- Vancomycin 1gm IV

Cerebral Contusion / Intracerebral Hemorrhage

• Often a/w SAH
• ICH can occur days after trauma often at site of resolving contusions
  • More common in pts w/ coagulopathy

Subarachnoid Hemorrhage

• Most common CT abnormality in moderate-severe TBI
• +Meningeal signs
• Associated with nonaccidental trauma in infants

Epidural Hematoma

• Due to trauma to temporoparietal area w/ associated skull fx and meningeal artery damage
• Classic presentation of LOC > lucid interval > LOC only occurs in 20%
• Injury to brain is often absent so good recovery if hematoma evacuated in time

Subdural Hematoma

• Often a/w underlying parenchymal damage
• More common in elderly, alcoholics, children <2yr
• May be acute (rapid LOC) or chronic (AMS w/ gradual decrease in consciousness)

DDx

1. DAI
2. Contusion/intracerebral hematoma
3. Epidural
4. Subdural
5. Traumatic SAH
6. Concussion

Treatment

Prevent further brain injury

1. Head of bed @ 30 degrees
2. Prevent:
   1. Hypotension
   2. Hypoxia
   3. Anemia
   4. Hyperthermia
   5. Coagulopathy
3. Seizure Prophylaxis (Trauma)

Increased ICP

1. Ensure adequate sedation (prevent gag reflex)
2. IVF to goal MAP >80 (maintains cerebral perfusion)
3. Mannitol
   1. Consider as long as pt is not hypotensive
   2. Reduces ICP w/in 30min; duration of action of 6-8hr
   3. Bolus 0.25-1 gm/kg
   4. Monitor I+O to maintain euvolemia
4. Hyperventilation
   1. No longer recommended as prophylactic intervention
      1. Hyperventilation to PaCO2 <25 never indicated
   2. Brief course only recommended if impending herniation (i.e., Cushing reflex)
      1. 1. Maintain PaCO2 30-35
5. Seizure
   1. Treat immediately
   2. Seizure prophylaxis reduces sz but does not improve long-term outcome

See Also

• Glasgow Coma Scale (GCS)
• Head Trauma (Peds)
• Concussion

Source

• Annals 2/09, Stein
• Tintinalli