What to do for a head trauma patient with normal vital signs?

Management of Head Trauma Patients with Normal Vital Signs

For head trauma patients with normal vital signs, perform an urgent neurological evaluation including pupil assessment, Glasgow Coma Scale motor score, and brain CT scan to determine the severity of brain damage and guide appropriate management. 1

Initial Assessment

• Perform urgent neurological evaluation including pupils examination and Glasgow Coma Scale (GCS) motor score assessment to determine severity of brain injury 1
• Obtain brain and cervical CT scan without delay to identify potential intracranial injuries 1
• Consider using transcranial Doppler as part of the initial assessment to evaluate brain hemodynamics and estimate cerebral perfusion 1
• Assess for signs requiring immediate tracheal intubation despite normal vital signs, including:
  • GCS ≤ 8
  • Significantly deteriorating conscious level (fall in GCS of two points or more)
  • Loss of protective laryngeal reflexes
  • Bilateral fractured mandible
  • Copious bleeding into the mouth 1

Management Based on CT Findings

If Life-Threatening Brain Lesions Present:

• Urgent neurosurgical consultation and intervention is required 1
• Position patient with 20-30° head-up tilt to reduce intracranial pressure (ICP) 1
• Maintain systolic blood pressure > 100 mmHg or mean arterial pressure > 80 mmHg 1

If At Risk for Intracranial Hypertension:

• Consider ICP monitoring in patients in coma with radiological signs of intracranial hypertension 1
• Maintain PaO₂ ≥ 13 kPa and PaCO₂ between 4.5-5.0 kPa 1
• If signs of cerebral herniation develop, administer osmotherapy with mannitol 0.25-2 g/kg as a 15-25% solution over 30-60 minutes 2

Transfer Considerations

• Transfer patients to a specialized center with neurosurgical facilities as soon as possible 1
• Ensure proper positioning during transfer with 20-30° head-up tilt while maintaining spinal immobilization if indicated 1
• During transfer, maintain continuous monitoring of vital signs and neurological status (pupil size and responses) 1
• Prepare appropriate medications for transfer including:
  • Sedatives (if intubated)
  • Analgesics
  • Anticonvulsants
  • Mannitol 20% or hypertonic saline
  • Vasoactive drugs (ephedrine, metaraminol, noradrenaline) 1

Common Pitfalls to Avoid

• Do not delay neurological evaluation and brain CT scan in head trauma patients, even with normal vital signs, as deterioration can occur rapidly 1
• Avoid hypoxia and hypercarbia which can increase intracranial pressure and cause secondary brain damage 3
• Do not transport patients with unstable vital signs; stabilize first before transfer 1
• Remember that normal vital signs do not exclude serious intracranial pathology; vigilant monitoring is still required 1
• Avoid excessive fluid administration which may worsen cerebral edema; use isotonic solutions (0.9% saline) when fluids are needed 1

Special Considerations

• Compliance with Brain Trauma Foundation guidelines for ICP monitoring is generally poor but should be followed when indicated 4
• For patients requiring emergency neurosurgery, maintain platelet count > 50,000/mm³ (higher values are advisable) 1
• Maintain blood glucose levels between 6-10 mmol/L 1
• Despite normal vital signs, consider the possibility of occult hemorrhage elsewhere that may later manifest as hemodynamic instability 1

Remember that even with normal vital signs, head trauma patients require careful monitoring as their condition can deteriorate rapidly. Early transfer to a specialized neurosurgical center improves outcomes in patients with severe traumatic brain injury 1.