Management of Head Injury This publication is designed to offer information suitable for use by an appropriately trained physician. The information p

Management of Head Injury

This publication is designed to offer information suitable for use by an appropriately trained physician. The information provided is not intended to be comprehensive or to offer a defined standard of care. The user agrees to release and indemnify the American College of Surgeons from claims arising from the use of the publication.

By Thomas G. Saul, MD, FACS, in conjunction with the Joint Section on Neurotrauma and Critical Care of the American Association of Neurological Surgeons and Congress of Neurological Surgeons

I. Initial Management

A. Airway

  • Intubate if:

    1. Airway or ventilation is inadequate.

    2. Patient remains unresponsive (cannot protect airway).

    3. Patient requires sedation for diagnostic maneuvers.

  • If C-spine injury is suspected, intubation should be performed by the most experienced person available. Use techniques that cause the least movement of the head and neck.

B. Breathing

  • Maintain PCO2 > 35 mmHg at normal levels.

C. Circulation

  • Shock is usually due to bleeding from other sources.

  • Control bleeding.

  • Fluid resuscitate with isotonic saline solutions as dictated by other body injuries.

  • Keep systolic blood pressure > 90 mmHg, as shock will worsen the head injury.

II. Initial Neuro-Assessment

Key History

  • Mechanism of injury.

  • Response at the scene.

Examination: Glasgow Coma Scale (GCS)

  • Best Eye Opening
    4. Spontaneous.
    3. To voice.
    2. To pain.

    1. None.

  • Best Verbal Response
    5. Converses, oriented.
    4. Converses, disoriented.
    3. Inappropriate words.
    2. Incomprehensible sounds.

    1. No verbalization.

  • Best Motor Response
    6. Obeys commands.
    5. Localizes painful stimuli.
    4. Withdraws from painful stimuli (flexion-withdrawal).
    3. Abnormal flexion (decorticate).
    2. Abnormal extension (decerebrate).

    1. Flaccid (no response).

  • GCS Total: 3–15.

Note Symmetry of Motor Examination

  • Do both arms move the same and equally strong?

  • Do both legs move the same and equally strong?

  • Asymmetrical motor responses should increase suspicion of an intracranial mass lesion requiring immediate operation.

Examine Pupils and Record:

  • Size, Shape, and Reaction:

    • Right: Brisk / Sluggish / None.

    • Left: Brisk / Sluggish / None.

    • An oval pupil or sluggish reaction may indicate impending herniation.

III. Immediate Neurosurgical Management

Obtain CT Scan of Head If:

  • Patient is comatose.

  • GCS ≤ 13.

  • Lateralizing neuro-examination reveals:

    • Unequal pupils.

    • Focal weakness.

Contact Neurosurgeon Immediately If:

  • Patient is comatose.

  • GCS ≤ 13.

  • CT scan is abnormal.

  • Lateralizing findings exist (e.g., dilating pupil or focal weakness).

IV. Recognize and Treat Herniation

Look for:

  • Sudden deterioration in level of consciousness.

  • Dilating pupil (especially on the side opposite to the lesion).

  • Deterioration of motor response.

Treatment:

  1. Hyperventilation (PCO2 = 25–30 mmHg).

  2. Mannitol 1 g/kg IV push (if BP stable and after neurosurgical consultation).

  3. Immediate CT scan or surgical intervention as directed by a neurosurgeon.

V. Other Considerations

  • Obtain a lateral C-spine X-ray (C1–C7/T1). Spine fractures are present in 5%–20% of patients with severe head injuries.

  • Remove the patient from the spine board but log-roll until the spine is radiographically cleared.

  • Immobilize the head and neck.

  • Obtain chest X-ray and check ABGs or end-tidal CO2 regularly.

  • Control bleeding and immobilize obvious extremity fractures.

VI. Pitfalls

  1. Assume a spine injury until ruled out.

  2. Use an orogastric tube (not nasogastric) if an anterior basilar skull or midface fracture is suspected.

  3. Hyperextension or direct neck trauma can cause carotid artery injury.

  4. Systolic BP < 90 mmHg can lead to secondary brain injury.

  5. Do not attribute neurologic abnormalities solely to drugs or alcohol.In such cases, a thorough assessment is required to differentiate between potential traumatic causes and substance-related effects, ensuring that the appropriate interventions are implemented without delay.