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severe head injury

Glasgow coma scale (GCS) < 9. Classification: - severe head injuries include: a) cerebral contusion b) intracerebral hematoma c) epidural hematoma (some) d) subdural hematoma (some) Procedure: ATLS protocol: 1) intubate 2) arterial blood gas 3) maintain SBP > 100 mm Hg 4) maintain spine precautions Physical examination: Neuro exam: 1) GCS 2) pupil size, reactivity to light, symmetry (prior to administration of atropine, if given) 3) motor & sensory exam, reflexes 4) signs of increased intracranial pressure a) decerebrate posturing b) decorticate posturing c) dilated pupils - unilateral or bilateral d) asymmetric pupillary activity e) worsening neurologic status, unexplained by extracranial causes Laboratory: 1) complete blood count (CBC) 2) chem-7 (electrolytes, BUN, creatinine, glucose) 3) type & screen 4) prothrombin (PT) & partial thromboplastin (PTT) time 5) urine toxicology 6) blood alcohol level (BAL) 7) arterial blood gas (ABG) Radiology: CT of head without contrast Management: 1) surgical lesion a) to operating room for surgical therapy b) insertion of intracranial pressure (ICP) monitor 2) contusions, edema, mass effect or abnormal basal cisterns a) ventriculostomy or ICP monitor 1] correct bleeding diathesis, if present, prior to insertion 2] Ancef 1.0 g IV for penetrating injury within 2 hours prior to insertion 3] vancomycin 1.0 g IV if cephalosporin allergy b) fosphenytoin loading 3) if no significant findings, prepare to ICP monitor 4) arterial line 5) central venous catheter for central venous pressure (CVP) 6) if no signs of increased ICP: a) mantain normal pCO2 b) no mannitol given 7) signs of increased ICP a) sedation morphine, midazolam (Versed) or propofol (Diprivan) b) hyperventilation: goal pCO2 30-35 mm Hg c) mannitol 1.0 gm/kg IV after volume replacement as hemodynamic status allows 8) prophylactic anticonvulsants for at least 1 week - loss of consciousness 12-24 hours - intracranial hemorrhage - depressed skull fracture - brain contusion [2]

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Glasgow coma scale (GCS) increased intracranial pressure (ICP)

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head injury

References

  1. CHS protocol 11/98
  2. Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018