What is the management of a patient with trauma and head injury leading to unresponsiveness?

Management of Trauma Patient with Head Injury Leading to Unresponsiveness

The management of an unresponsive trauma patient with head injury requires immediate airway control through tracheal intubation, mechanical ventilation with normoventilation (PaCO2 4.5-5.0 kPa), and maintenance of systolic blood pressure >110 mmHg, while simultaneously addressing other traumatic injuries. 1

Initial Assessment and Airway Management

• Immediately assess and secure the airway through tracheal intubation in all unresponsive head injury patients to ensure adequate oxygenation and ventilation 1
• Control ventilation through mechanical ventilation with end-tidal CO2 monitoring to maintain PaCO2 of 4.5-5.0 kPa (normoventilation) 1
• Avoid routine hyperventilation as it can cause cerebral vasoconstriction and decreased cerebral blood flow, potentially worsening brain ischemia 1
• Brief hyperventilation (PaCO2 not less than 4 kPa) is justified only for short-term use in cases of clinical or radiological evidence of raised intracranial pressure (ICP) with impending uncal herniation 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion 1
• Avoid any episode of hypotension (systolic BP <90 mmHg) as it significantly worsens neurological outcomes 1
• Use isotonic fluids (0.9% saline) for volume resuscitation to maintain hydration without causing cerebral edema 1
• If hypotension persists after correction of hypovolemia, use vasopressors such as phenylephrine or norepinephrine 1
• Position the patient with a 20-30° head-up tilt to improve venous drainage while maintaining spinal immobilization 1

Imaging and Diagnostic Assessment

• Perform immediate CT scan of the brain with bone windows as the first-line imaging modality to assess the extent of injury and identify associated intracranial lesions 1, 2
• Consider CT-angiography if there are risk factors for traumatic dissection of supra-aortic and intracranial arteries 1
• Assess the extent of traumatic hemorrhage using a combination of mechanism of injury, patient physiology, anatomical injury pattern, and response to initial resuscitation 1

Management of Intracranial Hypertension

• For signs of increased intracranial pressure, consider osmotic diuretics such as mannitol (0.25-2 g/kg IV administered over 30-60 minutes) 3
• External ventricular drainage can be performed to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1, 4
• Consider decompressive craniectomy to control intracranial pressure in cases of refractory intracranial hypertension following multidisciplinary discussion 4
• Avoid corticosteroids as they have not demonstrated beneficial effects on mortality or neurological outcomes in traumatic brain injury patients 4

Sedation and Analgesia

• Maintain appropriate sedation and analgesia through continuous infusion to prevent increases in intracranial pressure 1
• Consider neuromuscular blockade in addition to sedation to facilitate mechanical ventilation and prevent increases in intracranial pressure during procedures 1
• Target-controlled infusion (TCI) of sedatives may be preferred if available, with careful titration to avoid hypotension 1

Management of Multiple Trauma

• Prioritize control of major hemorrhage before transfer, as hypotension should be assumed to be due to hemorrhage in trauma patients 1
• Apply tourniquets for severe extremity hemorrhage that cannot be controlled by direct pressure, but keep time of application as short as possible 1
• The role of permissive hypotension should only be considered in exceptional circumstances for multiply-injured patients with traumatic brain injury 1

Transport Considerations

• Ensure proper securing and padding of the patient with due regard to possible spinal injury during transport 1
• Maintain 20-30° head-up tilt during transport while ensuring spinal immobilization 1
• Continue monitoring of vital signs, especially blood pressure and end-tidal CO2, throughout transport 1

Common Pitfalls and Caveats

• Avoid hyperventilation as it can cause cerebral vasoconstriction and worsen outcomes 1
• Prevent hypotension at all costs as even a single episode significantly worsens neurological outcomes 1
• Avoid hypertonic solutions (except when specifically indicated for raised ICP) as they may increase brain water content 1
• Do not delay transport to a facility capable of definitive management, as field management is limited 5
• Neurological assessment may be limited in severe cases, making imaging findings more critical for decision-making 2