What are the guidelines for managing head trauma?

Head Trauma Management Guidelines

Initial Assessment and Stabilization

The management of head trauma should prioritize prevention of secondary brain injury through maintaining adequate cerebral perfusion, oxygenation, and prompt identification and treatment of intracranial pathology. 1

Primary Survey (ABCDE)

• Airway: Secure with cervical spine protection
• Breathing: Ensure adequate oxygenation (maintain SpO2 >95%)
• Circulation: Control bleeding and maintain systolic BP >90 mmHg
• Disability: Glasgow Coma Scale (GCS) assessment
• Exposure: Complete examination for associated injuries

Immediate Interventions

• Intubation criteria: GCS ≤8, significantly deteriorating conscious level (fall in GCS of ≥2 points or motor score ≥1 point), or inability to protect airway 1
• Oxygenation: Maintain SpO2 >95% to prevent secondary brain injury 1
• Blood pressure management:
  • For patients without TBI: Restricted volume replacement with target SBP 80-90 mmHg until bleeding controlled
  • For patients with severe TBI (GCS <8): Maintain MAP ≥80 mmHg 1

Neurological Assessment

Glasgow Coma Scale (GCS)

• Mild TBI: GCS 13-15
• Moderate TBI: GCS 9-12
• Severe TBI: GCS ≤8

Pupillary Assessment

• Check size, symmetry, and reactivity
• Fixed, dilated pupil may indicate uncal herniation requiring immediate intervention

Imaging

CT Brain Indications

• GCS <15 at 2 hours post-injury
• Suspected open, depressed, or basal skull fracture
• Signs of basal skull fracture (raccoon eyes, Battle's sign, CSF otorrhea/rhinorrhea)
• Post-traumatic seizure
• Focal neurological deficit
• More than one episode of vomiting
• Age >65 years
• Coagulopathy or high-energy mechanism
• Retrograde amnesia >30 minutes 1

Additional Imaging

• CT cervical spine for patients with altered consciousness or neck pain/tenderness
• CT angiography for patients with risk factors for vascular injury (cervical spine fracture, focal neurological deficits, skull base fractures) 2

Management of Intracranial Hypertension

Monitoring

• ICP monitoring indications: GCS ≤8 with abnormal CT findings, evidence of mass effect, or basal cistern compression 1
• Target parameters:
  • ICP <20 mmHg
  • Cerebral Perfusion Pressure (CPP) ≥60 mmHg 1

First-Line Measures

• Elevate head of bed 20-30° to improve venous drainage 1
• Maintain euvolemia
• Treat fever and seizures
• Ensure adequate sedation and analgesia

Second-Line Measures

• Osmotic therapy: Mannitol 0.25-2 g/kg IV over 30-60 minutes 3
• Hyperventilation: Only for acute neurological deterioration (target PaCO2 30-35 mmHg)
• Surgical decompression: Consider for refractory intracranial hypertension 1

Surgical Management

Indications for Surgical Intervention

• Extradural hematoma >30 mL
• Subdural hematoma >10 mm thickness or midline shift >5 mm
• Intracerebral hemorrhage >30 mL with mass effect
• Open skull fracture with depression greater than skull thickness
• Compound depressed skull fracture 1

Transfer Guidelines

Criteria for Transfer to Neurosurgical Center

• Need for neurosurgical intervention
• Persistent GCS ≤8 after resuscitation
• Deteriorating GCS (drop of ≥2 points)
• Progressive focal neurological deficits
• Seizures without full recovery
• Penetrating head injury
• CSF leak
• Polytrauma with significant TBI 1

Transfer Considerations

• Stabilize patient before transfer
• Avoid transfer of hypotensive or hypoxic patients
• Ensure appropriate monitoring during transport
• Communicate with receiving facility 1

Special Considerations

Anticoagulation/Antiplatelet Therapy

• Patients on anticoagulants require urgent CT brain even with minor head injury
• Consider reversal of anticoagulation in patients with intracranial hemorrhage

Pediatric Patients

• Lower threshold for imaging and admission
• Consider non-accidental injury in children with inconsistent history
• Age-appropriate GCS assessment

Elderly Patients

• Higher risk of intracranial hemorrhage even with minor trauma
• Lower threshold for imaging and admission
• Consider comorbidities and medications

Prevention of Complications

Early Measures

• DVT prophylaxis within 24 hours after bleeding has been controlled 1
• Stress ulcer prophylaxis
• Normothermia maintenance
• Glycemic control
• Early mobilization when stable

Discharge Instructions

Mild TBI Discharge Criteria

• GCS 15
• Normal neurological examination
• No concerning CT findings
• Adequate home supervision

Warning Signs (Return to Hospital)

• Worsening headache
• Persistent vomiting
• Increasing drowsiness
• New weakness or numbness
• Seizure activity
• Clear fluid from nose or ears

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with head trauma through systematic assessment, appropriate monitoring, and timely interventions to prevent secondary brain injury.