What is the management plan for a patient with a head injury from a Road Traffic Accident (RTA) in the emergency setting?

Management of RTA Head Injury in Emergency Setting: A to Z Approach

The management of a patient with traumatic brain injury (TBI) from a road traffic accident requires immediate airway control with rapid sequence intubation, maintenance of systolic blood pressure >110 mmHg, and urgent CT scan to guide interventions. 1, 2

Initial Assessment and Resuscitation

1. Primary Survey (ABCDE)

• Airway:

  • Secure airway with rapid sequence intubation in severe TBI 1, 3
  • Avoid hypotensive induction agents 2
  • Use propofol as preferred sedative due to its favorable pharmacokinetic profile and ability to decrease intracranial pressure 1
  • Consider dexmedetomidine as an alternative non-benzodiazepine sedative 1

• Breathing:

  • Maintain oxygenation (PaO₂ ≥ 97.5 mmHg) 1
  • Control ventilation with normoventilation (PaCO₂ 34-38 mmHg) 2, 1
  • Use end-tidal CO₂ monitoring to guide ventilation 2
  • Avoid hyperventilation unless signs of imminent cerebral herniation 2
  • Use low tidal volume ventilation (6 ml/kg) with moderate PEEP 2

• Circulation:

  • Maintain systolic blood pressure >110 mmHg 2, 1
  • Rapidly correct hypotension using vasopressors (phenylephrine, norepinephrine) 2
  • Ensure euvolemia and maintain MAP >80 mmHg for ICP control 1
  • Control external hemorrhage with direct pressure; consider tourniquet for severe extremity bleeding 2

• Disability:

  • Perform neurological assessment (GCS, pupillary response, lateralizing signs)
  • Assess for signs of increased intracranial pressure
  • Evaluate for cerebellar dysfunction 1

• Exposure:

  • Complete trauma assessment for associated injuries
  • Maintain normothermia

2. Secondary Survey

• Complete head-to-toe examination
• Identify associated injuries (spine, chest, abdomen, extremities)
• Maintain cervical spine immobilization until cleared

Diagnostic Evaluation

1. Imaging

• Urgent brain and cervical CT scan with inframillimetric sections and double fenestration (CNS and bones) 2, 1

• CT-angiography for patients with risk factors for vascular injury 2:

  • Cervical spine fracture
  • Focal neurological deficit not explained by brain imaging
  • Claude Bernard-Horner syndrome
  • Lefort II or III facial fractures
  • Basal skull fractures
  • Soft tissue lesions at the neck

• Consider MRI with specialized sequences for detecting hemorrhagic axonal injuries 1

2. Monitoring

• Intracranial pressure monitoring for severe TBI with neurological deterioration 1
• Transcranial Doppler as part of initial assessment 1
• Continuous EEG monitoring to detect nonconvulsive seizure activity 1
• Regular neurological assessments to track recovery and detect complications 1

Management of Specific Injuries

1. Surgical Interventions

• Immediate surgical intervention for 1:

  • Epidural hematoma
  • Significant subdural hematoma
  • Acute hydrocephalus
  • Open or closed displaced skull fractures with brain compression

• External ventricular drainage for persistent intracranial hypertension 2, 1

• Decompressive craniectomy for refractory intracranial hypertension 1

2. Medical Management

• ICP Management:

  • Maintain head elevation at 20-30° 1
  • Sedation and analgesia
  • CSF drainage if external ventricular drain placed
  • Osmotherapy (mannitol, hypertonic saline) for elevated ICP
  • Avoid hypotonic fluids

• Seizure Prophylaxis:

  • Consider antiepileptic drugs for high-risk patients

• Prevention of Secondary Injury:

  • Maintain normoglycemia
  • Prevent hyperthermia
  • Deep vein thrombosis prophylaxis
  • Stress ulcer prophylaxis

Multidisciplinary Care

• Coordinate care with neurosurgeon, neurologist, intensivist
• Early involvement of physical, occupational, and speech therapists 1
• Dental/oral health specialist consultation for associated facial trauma 1

Common Pitfalls and Caveats

1. Ventilation management: Hyperventilation is common during resuscitation but can worsen outcomes by causing cerebral vasoconstriction and ischemia 2, 4

2. Blood pressure control: Even a single episode of hypotension (SBP <110 mmHg) can significantly worsen neurological outcomes and increase mortality 2

3. Imaging interpretation: CT may miss diffuse axonal injuries that are better detected with MRI 1

4. Premature prognostication: Avoid premature decisions about withdrawal of life-sustaining treatments given the substantial recovery potential even in severely injured patients 1

5. Inadequate pre-hospital ventilation: Studies show that only 37.7% of patients receive both optimal oxygenation and adequate ventilation during pre-hospital care 4