What medications should be started in case of head trauma?

Medications for Head Trauma Management

For patients with head trauma, the primary medications to consider include sedatives, analgesics, osmotic agents, and blood pressure management medications, with specific regimens based on injury severity and clinical presentation. 1

Initial Medication Management

Sedation and Analgesia for Intubated Patients

• For patients requiring intubation (GCS ≤8 or deteriorating neurological status), use high-dose opioids combined with appropriate sedatives: 1
  • Fentanyl (3-5 μg/kg), alfentanil (10-20 μg/kg), or remifentanil (target-controlled infusion ≥3 ng/ml) 1
  • For hemodynamically unstable patients, ketamine 1-2 mg/kg is preferred as an induction agent 1
  • Neuromuscular blockade with rocuronium 1 mg/kg or suxamethonium 1.5 mg/kg 1

Pain Management for Non-Intubated Patients

• For headache management after mild TBI, use non-opioid analgesics: 1
  • Acetaminophen or ibuprofen as first-line treatment 1
  • Avoid opioids for headache management as they are not generally recommended for headache therapy 1
  • Caution patients about analgesic overuse which can lead to rebound headaches 1

Intracranial Pressure Management

Osmotic Agents

• For increased intracranial pressure (ICP), administer: 1
  • Mannitol 0.5 g/kg as a bolus for short-term ICP reduction 1
  • Alternative: hypertonic saline (2 ml/kg of 3% saline) 1
  • Note: Prolonged hypernatremia is not recommended for ICP control in severe TBI 1

Ventilation Management

• Target PaCO2 of 4.5-5.0 kPa (normal range) 1
• Brief hyperventilation (PaCO2 not less than 4 kPa) is justified only for short-term use with signs of impending herniation 1
• Maintain PaO2 ≥13 kPa or oxygen saturation ≥95% 1

Blood Pressure Management

Hypotension Management

• After correcting hypovolemia, use: 1
  • Small boluses of α-agonists (e.g., metaraminol) followed by infusion 1
  • Noradrenaline (via central venous catheter only) for persistent hypotension 1
  • Avoid permissive hypotension in TBI patients 1

Hypertension Management

• For hypertension, increase sedation and use: 1
  • Small boluses of labetalol 1
  • For intracerebral hemorrhage with systolic BP >150 mmHg presenting within 6 hours, blood pressure reduction is recommended if immediate surgery is not planned 1
  • For acute ischemic stroke candidates for thrombolysis, keep BP <185/110 mmHg 1

Seizure Management

Antiepileptic Drugs

• Routine use of antiepileptic drugs (AEDs) for primary seizure prevention is not recommended 1
• Consider AEDs only in patients with specific risk factors: 1
  • Chronic subdural hematoma
  • Past history of epilepsy
  • Acute subdural hematoma
  • If AEDs are used, levetiracetam is preferred over phenytoin due to better tolerability 1

Special Considerations

Anticoagulation Reversal

• For patients on anticoagulants with intracerebral hemorrhage: 1
  • Rapidly reverse anticoagulation while limiting fluid volumes
  • Use prothrombin complex concentrate rather than fresh frozen plasma for warfarin reversal
  • Administer vitamin K concurrently 1

Beta-Blockers

• Consider beta-blockers for severe TBI patients in ICU settings: 1
  • May reduce mortality when used in-hospital after TBI
  • Avoid in patients with symptomatic bradycardia or hypotension
  • Monitor for adverse cardiovascular events 1

Corticosteroids

• High-dose glucocorticoids are contraindicated after severe TBI as they increase mortality 1

Pitfalls and Caveats

• Avoid hypotonic fluids (Ringer's lactate, Ringer's acetate, gelatins) as they can increase brain water; use isotonic solutions like 0.9% saline 1
• Do not transport hypotensive patients until bleeding is controlled and hemodynamics are stabilized 1
• Avoid routine repeat imaging or admission for patients on anticoagulants with normal initial head CT and baseline neurological examination 1
• Monitor for analgesic overuse in headache management, which can lead to rebound headaches 1, 2
• Maintain serum glucose between 8-11 mmol/L (1.4-2.0 g/L) in severe TBI patients 1

By following these evidence-based medication guidelines for head trauma management, clinicians can optimize patient outcomes while minimizing secondary brain injury.