What is the management approach for a patient presenting with traumatic head injury and red flag signs such as severe headache, vomiting, seizures, confusion, or altered mental status?

Management of Traumatic Head Injury with Red Flag Signs

Patients presenting with traumatic head injury and red flag signs such as severe headache, vomiting, seizures, confusion, or altered mental status require immediate neuroimaging with CT scan and close monitoring for deterioration, as these symptoms indicate possible intracranial injury requiring urgent intervention.

Initial Assessment and Triage

Primary Survey

• Ensure airway patency, adequate breathing, and circulation (ABC)
• Assess Glasgow Coma Scale (GCS) score
  • GCS ≤14 indicates high risk and requires immediate attention 1
  • Document pupillary responses and cranial nerve examination
• Monitor vital signs, with particular attention to:
  • Blood pressure (hypertension may indicate increased intracranial pressure)
  • Heart rate (bradycardia may indicate Cushing's reflex)
  • Respiratory pattern (irregular breathing may indicate brainstem compression)

Red Flag Signs Requiring Immediate Action

• Altered mental status or confusion
• Severe or worsening headache
• Repeated vomiting
• Seizures
• Focal neurological deficits
• Visual disturbances
• Signs of basilar skull fracture (raccoon eyes, Battle's sign, CSF otorrhea/rhinorrhea)

Diagnostic Imaging

CT Scan

• Immediate non-contrast head CT is indicated for all patients with traumatic head injury presenting with any red flag signs 1, 2
• CT imaging should be performed without delay in patients with:
  • GCS score <15
  • Focal neurologic deficit
  • Vomiting
  • Severe headache
  • Age ≥65 years
  • Signs of basilar skull fracture
  • Coagulopathy
  • Dangerous mechanism of injury 1

MRI Considerations

• May be considered as a secondary imaging modality if CT is normal but symptoms persist
• More sensitive for detecting diffuse axonal injury, small contusions, and posterior fossa injuries
• May be challenging to obtain in acutely altered patients due to longer scan times and motion sensitivity 2

Management Protocol

Immediate Interventions

1. Stabilize ABC (Airway, Breathing, Circulation)

   • Intubate if GCS ≤8 or unable to protect airway
   • Maintain oxygen saturation >95%
   • Ensure adequate blood pressure (systolic BP >110 mmHg) to maintain cerebral perfusion 3

2. Manage Increased Intracranial Pressure (ICP)

   • Position head elevated at 30° unless contraindicated
   • For signs of herniation or acute deterioration:
     • Mannitol: 0.25-2 g/kg IV over 30-60 minutes 4
     • Avoid hyperventilation except as a temporary measure for acute herniation

3. Seizure Management

   • Administer benzodiazepines for active seizures
   • Consider prophylactic antiepileptic drugs only for high-risk patients (penetrating injury, intracranial hematoma, depressed skull fracture) 5

Ongoing Monitoring

• Serial neurological assessments every 15-30 minutes
• Monitor for signs of deterioration:
  • Decreasing GCS
  • Pupillary asymmetry or sluggish response
  • Worsening headache
  • New onset or worsening vomiting
  • Development of focal neurological deficits

Disposition and Definitive Care

Neurosurgical Consultation

• Immediate neurosurgical consultation for:
  • Abnormal CT findings (hemorrhage, midline shift, mass effect)
  • GCS ≤13 or declining
  • Persistent altered mental status
  • Focal neurological deficits
  • Seizures
  • Open or depressed skull fracture

ICU Admission Criteria

• All patients with:
  • GCS ≤13
  • Abnormal CT findings requiring monitoring
  • Need for ICP monitoring
  • Post-neurosurgical intervention
  • Persistent altered mental status despite normal CT

Ward Admission Criteria

• Patients with:
  • GCS 14-15 with abnormal CT not requiring neurosurgical intervention
  • GCS 15 with normal CT but persistent concerning symptoms
  • Need for extended observation due to comorbidities or anticoagulation

Common Pitfalls and Caveats

1. Delayed Deterioration

   • Patients may appear stable initially but deteriorate later due to evolving intracranial injuries
   • Repeat CT is indicated for any neurological deterioration

2. Anticoagulation/Coagulopathy

   • Patients on anticoagulants or with coagulopathies have higher risk of delayed bleeding
   • Lower threshold for imaging and longer observation period required
   • Consider repeat CT at 24 hours even if initial CT is normal

3. Elderly Patients

   • More susceptible to intracranial injuries despite seemingly minor trauma
   • May present with subtle symptoms
   • Lower threshold for imaging and admission

4. Intoxication Masking Symptoms

   • Alcohol or drug intoxication can mask traumatic brain injury symptoms
   • Err on the side of caution with imaging and observation until sober assessment possible

5. Isolated Evaluation of GCS

   • Relying solely on GCS without considering other red flag signs may miss significant injuries
   • Always evaluate the complete clinical picture

Remember that timely recognition and management of red flag signs in traumatic head injury significantly impacts morbidity and mortality outcomes. When in doubt, proceed with neuroimaging and neurosurgical consultation.