What is the immediate management for a patient with a head injury?

Immediate Management of Head Injury

Secure the airway immediately through tracheal intubation with mechanical ventilation and continuous end-tidal CO2 monitoring (targeting 30-35 mmHg) in all comatose patients, while simultaneously maintaining systolic blood pressure >110 mmHg from first contact, and obtain non-contrast brain and cervical spine CT without delay. 1, 2, 3

Airway and Ventilation (First Priority)

• Perform immediate tracheal intubation in all comatose head injury patients, even during pre-hospital care, as airway control is the absolute priority and decreases mortality. 1

• Monitor end-tidal CO2 continuously to verify correct tube placement and maintain PaCO2 between 30-35 mmHg initially, then 35-40 mmHg after stabilization. 1, 2, 4

• Avoid hypocapnia (PaCO2 <35 mmHg) as it induces cerebral vasoconstriction and increases risk of brain ischemia. 1

• Maintain oxygen saturation >95% and PaO2 between 60-100 mmHg throughout all interventions. 4, 5

Hemodynamic Management (Simultaneous Priority)

• Maintain systolic blood pressure >110 mmHg from the moment of first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome and increases mortality. 2, 3, 4

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 3

• Initiate crystalloid fluid therapy in hypotensive bleeding trauma patients, but avoid hypotonic solutions such as Ringer's lactate in patients with severe head trauma. 1

• Use continuous infusions rather than boluses of sedative agents to avoid hemodynamic instability. 3

Neurological Assessment

• Perform serial Glasgow Coma Scale assessments with particular attention to motor score and pupillary reflexes to detect clinical deterioration. 4, 5

• Monitor for signs of increased intracranial pressure: pupillary abnormalities, hypertension, and bradycardia. 2

• Recognize that deterioration after lucid interval most commonly occurs within 24 hours (71% of cases), with mass lesions found in 81% of patients who deteriorate. 2

Immediate Imaging

• Obtain non-contrast brain and cervical spine CT scan without delay to identify primary brain lesions and guide neurosurgical procedures. 2, 3, 4

• Use inframillimetric sections with double fenestration (central nervous system and bone windows) as the reference standard. 2, 3

• Consider CT-angiography of supra-aortic and intracranial vessels in patients with cervical spine fracture, focal deficit unexplained by brain imaging, or basal skull fractures. 2, 4

Transfer and Consultation

• Transfer immediately to a center with neurosurgical capabilities rather than delaying for "stabilization" at a non-neurosurgical facility. 2, 3

• Contact neurosurgery early if there is any possibility that consultation might enhance emergency management. 6

Urgent Neurosurgical Indications

Immediate surgical intervention is indicated for: 1, 2, 3

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

Intracranial Pressure Management

• Implement standard ICP management measures: restrict free water, avoid excess glucose, minimize hypoxemia and hypercarbia, treat hyperthermia, elevate head of bed 20-30°. 2

• Consider ICP monitoring in severe TBI patients (GCS <9) to guide therapy and maintain cerebral perfusion pressure ≥60 mmHg. 2, 4

• Use osmotic diuretics (mannitol 0.25-0.5 g/kg IV) to reduce ICP when clinically indicated. 2

• Consider external ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary brain insults. 1, 2, 4

Critical Pitfalls to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors—this is a common and dangerous error. 3

• Do not use corticosteroids as they have failed to demonstrate beneficial effects on mortality or neurological outcomes. 2

• Avoid using bolus sedation rather than continuous infusions, as this causes hemodynamic instability. 3

• Do not delay transfer to a specialized center for "stabilization" at a non-neurosurgical facility. 3

Sedation Considerations

• Use rapidly metabolized sedative and analgesic drugs to permit frequent neurological evaluation. 5

• Avoid barbiturates, bolus midazolam, or bolus opioids as first-line agents due to risk of arterial hypotension. 1

• Pay careful attention to systemic hemodynamics when choosing sedative agents and their administration modalities. 1

Coagulopathy Management (if bleeding present)

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage, with higher values advisable for emergency neurosurgery including ICP probe insertion. 4

• Maintain PT/aPTT <1.5 times normal control during interventions for life-threatening hemorrhage or emergency neurosurgery. 4

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery. 4