How to manage a 48-year-old patient with a history of Road Traffic Accident (RTA) with head injury?

From the Guidelines

Management of a 48-year-old patient with a history of road traffic accident (RTA) with head injury requires a systematic approach focusing on stabilization, assessment, and appropriate treatment, with the primary goal of minimizing morbidity, mortality, and optimizing quality of life. Initially, secure the airway, breathing, and circulation (ABC) while maintaining cervical spine immobilization 1. Perform a rapid neurological assessment using the Glasgow Coma Scale (GCS) to determine the severity of the head injury. Obtain immediate CT imaging of the brain to identify intracranial hemorrhage, contusions, or skull fractures. Monitor vital signs closely, including blood pressure, heart rate, oxygen saturation, and temperature. Maintain cerebral perfusion pressure by targeting a systolic blood pressure above 100 mmHg while avoiding hypertension.

Some key considerations in the management of such patients include:

• The risk of delayed intracranial hemorrhage (ICH) in patients on anticoagulants or antiplatelet agents, which, although rare, can be significant 1
• The importance of clear discharge instructions with return precautions, given the potential for up to approximately 5% of these patients to develop delayed ICH 1
• The need for early neurosurgical consultation, particularly if there are surgical lesions requiring evacuation 1
• The use of seizure prophylaxis in moderate to severe head injury, with options including levetiracetam or phenytoin 1
• The management of pain and maintenance of normothermia, normoglycemia, and adequate oxygenation to optimize recovery 1

The most critical aspect of management is the initial assessment and stabilization, followed by appropriate imaging and monitoring, with a focus on minimizing the risk of secondary brain injury and optimizing outcomes. Given the potential for significant morbidity and mortality associated with head injuries, a cautious and comprehensive approach is essential, with consideration of the latest evidence and guidelines 1.

From the Research

Management of a 48-year-old Patient with a History of RTA with Head Injury

• The patient's history of road traffic accident (RTA) with head injury indicates a high risk of post-traumatic seizures, which can be life-threatening and require prompt management 2, 3, 4.
• Studies have shown that antiepileptic medications such as phenytoin and levetiracetam can be effective in preventing post-traumatic seizures 2, 3, 5, 6.
• Phenytoin has been traditionally used for seizure prophylaxis, but it has a large side-effect profile and may not be suitable for all patients 2, 3.
• Levetiracetam has a better side-effect profile and may be a suitable alternative to phenytoin for seizure prophylaxis 2, 5, 6.

Seizure Prophylaxis

• The use of antiepileptic medications for seizure prophylaxis in patients with traumatic brain injury has been shown to be effective in reducing the incidence of early post-traumatic seizures 3, 6.
• Phenytoin should be started within 12 hours of injury to be effective in preventing early post-traumatic seizures 3.
• Levetiracetam has been shown to be effective in reducing the incidence of early post-traumatic seizures, but its efficacy in preventing late post-traumatic seizures is still uncertain 5, 6.

Risk Factors for Breakthrough Seizures

• Older age, higher Marshall score, and neurosurgical procedures for hematoma evacuation have been identified as risk factors for breakthrough early post-traumatic seizures despite the use of phenytoin prophylaxis 4.
• Patients with therapeutic phenytoin levels at the time of seizure still experienced breakthrough seizures, highlighting the need for close monitoring and adjustment of antiepileptic medication regimens 4.

Treatment Options

• Phenytoin and levetiracetam are both effective options for seizure prophylaxis in patients with traumatic brain injury, but the choice of medication should be individualized based on patient factors and side-effect profiles 2, 3, 5, 6.
• Further research is needed to evaluate the required duration of therapy and long-term safety profiles of antiepileptic medications in patients with traumatic brain injury 6.