What is the recommended treatment for a head injury?

Management of Head Injury

For severe traumatic brain injury (TBI), immediately secure the airway with endotracheal intubation, aggressively maintain systolic blood pressure >110 mmHg using vasopressors without delay, and obtain urgent non-contrast CT of the brain to guide neurosurgical intervention. 1

Initial Airway and Ventilation Management

• Establish airway control as the absolute priority through endotracheal intubation and mechanical ventilation, beginning in the pre-hospital period for severe TBI (Glasgow Coma Scale ≤8). 1, 2
• Monitor end-tidal CO2 continuously to maintain PaCO2 within normal range (30-35 mmHg), as hypocapnia induces cerebral vasoconstriction and risks brain ischemia. 3, 1
• Confirm correct endotracheal tube placement through end-tidal CO2 monitoring. 1
• Avoid prophylactic hyperventilation, as it reduces cerebral perfusion and worsens outcomes. 4

Hemodynamic Resuscitation

• 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. 1, 2, 5
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 1, 5
• Avoid hypotensive sedative agents and use continuous infusions rather than boluses to prevent hemodynamic instability. 1, 5

Imaging Strategy

• Obtain non-contrast CT of the brain and cervical spine immediately without delay to guide neurosurgical procedures and monitoring techniques. 3, 1, 2
• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows). 3, 2
• For patients on anticoagulants or antiplatelet agents (excluding aspirin alone) with minor head injury (GCS ≥14), a single initial CT scan is adequate for safe discharge if normal, as delayed intracranial hemorrhage is very rare (0.6% for warfarin, 0% for clopidogrel). 3

Neurosurgical Intervention Criteria

Perform surgical evacuation for: 1, 2, 5

• Symptomatic epidural hematoma (any location)
• Acute subdural hematoma with thickness >5mm and midline shift >5mm
• Brain contusions with mass effect
• Acute hydrocephalus requiring drainage
• Open displaced skull fracture
• Closed displaced skull fracture with brain compression

Intracranial Pressure Management

• Implement intracranial pressure (ICP) monitoring in severe TBI patients with abnormal CT findings (compressed basal cisterns, midline shift >5mm, intracerebral hematoma >25mL) or GCS ≤8 with normal CT if neurological examination is not feasible. 3, 1
• Treat intracranial hypertension (ICP >20 mmHg) with osmotic therapy using mannitol 0.25-2 g/kg IV over 30-60 minutes. 6
• Consider decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion, though this reduces mortality at the expense of increased severe disability. 3

Pharmacologic Management

• Administer tranexamic acid (TXA) 1g IV over 10 minutes followed by 1g infusion over 8 hours as soon as possible and within 3 hours of injury for patients with TBI and bleeding risk, as this reduces head injury-related death in mild-moderate TBI. 3
• Use propofol by continuous infusion (not bolus) in combination with normocapnia to decrease ICP independently of blood pressure changes. 1
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 2

Monitoring and Supportive Care

• Monitor serum sodium and potassium carefully during mannitol administration, as electrolyte imbalances and renal complications including acute kidney injury can occur. 6
• Implement detection and prevention strategies for post-traumatic seizures. 1, 2
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1, 2

Management of Mild-Moderate Head Injury (GCS 9-15)

• Hospitalize all patients with altered level of consciousness (GCS 9-14). 7
• Selected patients with GCS 15 benefit from overnight hospitalization and observation if they have risk factors such as anticoagulation, loss of consciousness, or post-traumatic amnesia. 3, 7
• CT scanning is the primary imaging modality for patients at risk for intracranial complications. 3, 7

Critical Pitfalls to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors. 1, 5
• Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability. 1, 5
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility. 1, 2, 5
• Never administer glucocorticoids for TBI, as they are not beneficial. 4
• Do not routinely hyperventilate, as this was shown to worsen outcomes despite historical practice patterns. 4