What is the treatment for a head injury?

Treatment for Head Injury

Immediate priorities are securing the airway, maintaining systolic blood pressure ≥110 mmHg, obtaining urgent CT imaging, and preventing secondary brain injury through control of hypoxia, hypotension, and intracranial pressure. 1

Initial Assessment and Stabilization

Airway and Breathing Management

• Secure the airway immediately with tracheal intubation for severe traumatic brain injury (TBI) patients (Glasgow Coma Scale ≤8) or those with deteriorating neurological status (GCS drop ≥2 points or motor score drop ≥1 point). 1
• Maintain mechanical ventilation with end-tidal CO2 monitoring to keep PaCO2 between 35-40 mmHg (normocapnia), as hypocapnia causes cerebral vasoconstriction and ischemia. 1
• Ensure adequate oxygenation to prevent hypoxemia, which occurs in 20% of TBI patients and significantly worsens mortality and neurological outcomes. 1
• Avoid prolonged hyperventilation as it induces cerebral ischemia through excessive vasoconstriction. 2, 3

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg before cerebral perfusion pressure can be measured directly. 1
• Even a single episode of hypotension (systolic BP <90 mmHg) dramatically worsens neurological outcome and mortality. 1
• Use vasopressor drugs (phenylephrine, norepinephrine) for rapid correction of hypotension rather than waiting for fluid resuscitation or sedation adjustment to take effect. 1
• Avoid hypotensive resuscitation strategies ("permissive hypotension") in TBI patients, even when managing concurrent hemorrhagic shock. 2, 4

Neurological Assessment

• Assess severity using the Glasgow Coma Scale, with particular attention to motor response, pupillary size, and reactivity as key prognostic indicators. 1, 2, 4
• Document the complete timeline: mechanism of injury, loss of consciousness, any lucid interval, and subsequent deterioration. 2, 4
• Perform frequent serial neurological examinations to detect early signs of deterioration. 2

Imaging Strategy

CT Scanning

• Obtain urgent brain and cervical spine CT scan without delay in all severe TBI patients (GCS ≤8) and moderate TBI patients (GCS 9-13). 1
• For mild TBI (GCS 14-15), use validated clinical decision rules (New Orleans Criteria or Canadian CT Head Rule) to determine imaging necessity. 1
• CT should include inframillimetric sections reconstructed >1mm thickness, visualized with both CNS and bone windows. 1
• Never delay neuroimaging in patients with a history of lucid interval, even if they appear currently stable, as they are at high risk for expanding intracranial lesions. 2, 4

CT Angiography

• Perform early CT angiography of supra-aortic and intracranial vessels in patients with risk factors for arterial dissection: cervical spine fracture, focal neurological deficit unexplained by brain imaging, Horner syndrome, LeFort II/III facial fractures, basilar skull fractures, or soft tissue neck injuries. 1

Intracranial Pressure Management

ICP Monitoring

• Implement ICP monitoring in severe TBI patients (GCS ≤8) with abnormal CT findings. 2, 4, 3
• Consider ICP monitoring in moderate TBI patients who experienced a lucid interval. 2, 4
• Target ICP <20 mmHg, as values of 20-40 mmHg significantly increase mortality risk. 3
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available. 2, 4

Tiered ICP Treatment Approach

First-tier interventions: 2, 4

• Ensure adequate sedation and analgesia
• Maintain normothermia (avoid fever, which worsens secondary injury) 1
• Treat seizures promptly
• Elevate head of bed to 30 degrees to improve venous drainage 2

Second-tier interventions: 2, 4

• Osmotic therapy with mannitol (0.25-2 g/kg) for clinical deterioration
• External ventricular drainage for persistent intracranial hypertension despite first-tier measures 1

Neurosurgical Intervention

Indications for Urgent Neurosurgical Consultation

Immediate neurosurgical consultation is mandatory for: 2, 4

• Epidural hematoma with mass effect
• Depressed skull fractures
• Open skull fractures with CSF leak or brain tissue exposure
• Any expanding intracranial lesion causing midline shift or significant mass effect
• Patients with history of lucid interval, even if currently stable

Transfer Considerations

• Patients requiring neurosurgical intervention should be transferred without delay to a neuroscience center, with target time from injury to surgery ≤4 hours for expanding hematomas. 1
• Patients must be accompanied by a clinician with appropriate training in brain injury transfer. 1
• Anterior circulation stroke patients for thrombectomy rarely need airway intervention during transfer. 1
• Maintain continuous monitoring during transport with mobile phone for urgent communication. 1

Critical Pitfalls to Avoid

• Never use hypotonic fluids, as they worsen cerebral edema. 2, 3
• Never assume stability in patients who appear well after initial injury—deterioration can be sudden, especially with lucid interval. 2, 3
• Never delay imaging or neurosurgical consultation based on current clinical appearance if mechanism or history suggests serious injury. 2, 4
• Avoid hypotensive hypnotic agents for sedation induction; use continuous sedation rather than boluses. 1
• Do not use permissive hypotension strategies in TBI patients, even with polytrauma. 2, 4

Special Populations

Pediatric Considerations

• Children require the same urgent neuroimaging and close monitoring as adults when head injury is suspected. 2, 3
• Use age-appropriate GCS scoring and maintain the same hemodynamic and respiratory targets. 3
• Diffuse cerebral swelling is more common in children and adolescents than adults. 5

Mild TBI/Concussion Management

• For mild TBI meeting imaging criteria by clinical decision rules, obtain CT to rule out surgical lesions. 1
• Provide comprehensive discharge instructions including warning signs of deterioration and expected symptom course. 3
• Recommend gradual return to activity with symptom monitoring rather than complete rest beyond the first few days. 3
• Most postconcussion symptoms resolve by 3-6 months, though a minority have persistent symptoms. 6