What is the appropriate treatment and management for a patient with a head injury?

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Last updated: November 7, 2025View editorial policy

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Head Injury Management

Initial Assessment and Severity Classification

Management of head injury must be stratified by severity using the Glasgow Coma Scale (GCS), with immediate CT imaging for moderate-to-severe injuries (GCS ≤13) and selective imaging based on validated clinical decision rules for mild injuries (GCS 14-15). 1

Severity Classification

  • Severe TBI: GCS ≤8 2
  • Moderate TBI: GCS 9-13 2
  • Mild TBI: GCS 14-15 1

The motor component of the GCS is the most robust predictor, particularly in sedated patients, and pupillary size and reactivity are critical prognostic factors requiring repeated assessment. 2

Mild Head Injury (GCS 14-15)

Imaging Decision Rules

For mild head injury, CT scanning should be selective and guided by validated clinical decision rules rather than routine imaging of all patients. 1

Only 10% or less of mild head trauma cases show positive CT findings, and only 1% or less require neurosurgical intervention, making universal CT scanning inefficient. 1

High-Risk Criteria (Canadian CT Head Rule - 100% sensitive for neurosurgical intervention):

  • Failure to reach GCS 15 within 2 hours 1
  • Suspected open or depressed skull fracture 1
  • Signs of basal skull fracture 1
  • Vomiting more than once 1
  • Age >64 years 1

Medium-Risk Criteria (98.4% sensitive for clinically important brain injury):

  • Retrograde amnesia >30 minutes 1
  • Dangerous mechanism of injury 1

Patients with mild head injury and NO high-risk or medium-risk criteria can be safely discharged with written instructions and do not require CT imaging. 1, 3

Observation and Discharge

Patients with normal CT scans require only brief observation before discharge with warning instructions. 3 If CT is unavailable and skull X-ray is negative, patients can be discharged after observation. 3

Moderate-to-Severe Head Injury (GCS ≤13)

Immediate Neuroimaging

All patients with moderate or severe head injury require immediate non-contrast CT of the brain and cervical spine without delay to identify surgical lesions and guide management. 4, 2

  • Use inframillimetric sections with dual windowing (brain and bone) 4
  • Consider CT angiography for patients with cervical spine fractures, basal skull fractures, or focal deficits unexplained by brain imaging 4

Airway and Ventilation Management

Patients with severe TBI (GCS ≤8) require immediate tracheal intubation and mechanical ventilation with continuous end-tidal CO₂ monitoring. 1, 4

Ventilation Targets:

  • PaO₂ ≥13 kPa (≥98 mmHg) - avoid even brief hypoxic episodes 1
  • PaCO₂ 4.5-5.0 kPa (34-38 mmHg) 1
  • Minimum PEEP 5 cmH₂O to prevent atelectasis; PEEP up to 10 cmH₂O does not adversely affect cerebral perfusion 1

Emergency hyperventilation (PaCO₂ not less than 4 kPa/30 mmHg) is justified only for impending uncal herniation and should be brief, combined with osmotic therapy. 1, 4

Hemodynamic Management

Maintain systolic blood pressure >110 mmHg (mean arterial pressure ≥80 mmHg) to ensure adequate cerebral perfusion. 4, 2

Hypotension (SBP <90 mmHg) dramatically increases mortality and morbidity, and the combination of hypotension with hypoxemia carries a 75% mortality rate. 2

Fluid Resuscitation:

  • Use 0.9% normal saline exclusively - it is the only truly isotonic crystalloid solution 1
  • Avoid Ringer's lactate, Ringer's acetate, and gelatins (hypotonic when measured by real osmolality) 1
  • Do NOT use albumin or synthetic colloids in early management 1
  • Reverse hypovolemia before transfer; never transfer hypotensive, actively bleeding patients 1

Blood Pressure Management:

  • For hypotension after correcting hypovolemia: use α-agonist boluses (metaraminol) or noradrenaline infusion via central line 1
  • For hypertension: increase sedation and use small labetalol boluses 1
  • Measure arterial pressure at the level of the tragus, especially with head elevation 1

Patient Positioning

Position patients with 20-30° head-up tilt while maintaining spinal immobilization. 1

Intracranial Pressure Monitoring

ICP monitoring is indicated for severe TBI patients (GCS <9) with abnormal CT findings, particularly compressed basal cisterns, which is the strongest predictor of intracranial hypertension. 1

ICP >20-40 mmHg increases mortality risk 3.95-fold, and ICP >40 mmHg increases it 6.9-fold. 1

Management of Elevated ICP

First-Line Measures:

  • Elevate head of bed 20-30° 4
  • Restrict free water and avoid excess glucose 4
  • Treat hyperthermia 4
  • Optimize sedation and analgesia 1
  • Correct hypoxemia and hypercarbia 4

Second-Line Interventions for Refractory ICP:

  • External ventricular drainage for persistent intracranial hypertension 4, 2
  • Mannitol 0.25-0.5 g/kg IV (or 0.5 g/kg per guidelines) 1, 4
  • Hypertonic saline 2 ml/kg of 3% saline for clinical herniation 1, 4, 2

Neurosurgical Indications

Immediate surgical intervention is required for: 4

  • Symptomatic extradural hematoma (any location)
  • Acute subdural hematoma >5 mm thickness with >5 mm midline shift
  • Acute hydrocephalus requiring drainage
  • Open displaced skull fracture requiring closure
  • Closed displaced skull fracture with brain compression

Decompressive craniectomy should be considered for refractory intracranial hypertension after multidisciplinary discussion. 1 Large temporal craniectomy (>100 cm²) with dural expansion can reduce mortality from 49% to 27% but may increase survival with severe disability. 1

Transfer Considerations

Transfer to a neurosurgical center must occur as quickly as possible after initial stabilization. 4 Patients must be hemodynamically stable, adequately oxygenated and ventilated, and have controlled bleeding before transfer. 1

Critical Pitfalls to Avoid

NEVER use corticosteroids for traumatic brain injury - they provide no mortality or neurological benefit. 4, 2

Deterioration after a lucid interval occurs in 71% of cases within 24 hours, with mass lesions found in 81% of these patients. 4 This mandates close observation even in initially stable patients.

Avoid permissive hypotension in TBI patients - unlike other trauma, brain injury requires maintained cerebral perfusion pressure. 1

Do not routinely hyperventilate - use only briefly for impending herniation as prolonged hyperventilation causes cerebral ischemia. 1, 4

Monitoring Parameters

Transcranial Doppler Concerning Findings:

  • Diastolic blood flow velocity <20 cm/s 4, 2
  • Pulsatility index >1.4 4, 2

Clinical Warning Signs:

  • Pupillary abnormalities 4
  • Hypertension with bradycardia (Cushing's triad) 4
  • Declining GCS 2

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Manejo del Traumatismo Craneoencefálico

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Management of Patients with Lucid Interval After Head Trauma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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