What is the management of a patient with a head injury from a fall?

Management of Fall with Head Injury

All patients with head injury from a fall require immediate assessment of injury severity using the Glasgow Coma Scale (GCS), urgent CT imaging in most cases, and aggressive prevention of secondary brain injury through maintenance of adequate cerebral perfusion and oxygenation. 1, 2

Initial Assessment and Resuscitation

Airway and Breathing Management

• Intubate immediately if GCS ≤8, deteriorating consciousness (fall in GCS ≥2 points or motor score ≥1 point), loss of protective airway reflexes, inability to maintain PaO2 ≥13 kPa, or PaCO2 >6 kPa. 1
• Maintain normocapnia with PaCO2 between 4.5-5.0 kPa (35-40 mmHg) throughout—hyperventilation causes cerebral ischemia and should be avoided except briefly for impending uncal herniation. 1
• Target PaO2 ≥13 kPa or oxygen saturation ≥95% to prevent hypoxemia, which significantly worsens outcomes. 1
• Monitor end-tidal CO2 continuously in intubated patients to verify tube placement and maintain appropriate ventilation. 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg at minimum—even a single episode of hypotension (SBP <90 mmHg) dramatically worsens neurological outcomes. 1, 2
• Use vasopressors (phenylephrine, metaraminol, or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment to take effect. 1
• Avoid "permissive hypotension" strategies entirely in head-injured patients, even with concomitant hemorrhagic injuries. 2, 3
• Elevate head of bed to 30 degrees to improve venous drainage while maintaining cervical spine precautions if indicated. 2

Neurological Assessment

• Document GCS score with particular attention to motor response component, pupillary size and reactivity—these are key prognostic indicators. 2, 3, 4
• Record timeline meticulously: mechanism of injury, any loss of consciousness, presence of lucid interval, and subsequent deterioration. 2, 3
• Perform frequent serial neurological examinations to detect early deterioration—patients with initial lucid intervals can deteriorate suddenly and unpredictably. 2, 4

Neuroimaging Strategy

CT Imaging Indications

• Obtain urgent non-contrast head CT immediately in all patients with GCS ≤14, loss of consciousness, post-traumatic amnesia, focal neurological deficits, or anticoagulant/antiplatelet use (excluding aspirin alone). 1
• Perform CT angiography of supra-aortic and intracranial vessels if cervical spine fracture, unexplained focal deficit, Horner syndrome, LeFort II/III facial fractures, skull base fractures, or neck soft tissue injury present. 1
• Include cervical spine CT in all severe head trauma patients. 1
• Do not delay CT imaging in patients with history of lucid interval, even if currently neurologically stable—this population has high risk for expanding lesions. 2, 3, 4

Special Populations: Anticoagulation/Antiplatelet Therapy

• A single initial head CT without hemorrhage is sufficient for discharge in patients on warfarin or clopidogrel (excluding aspirin) with minor head injury (GCS ≥14) who remain at neurological baseline. 1
• Routine repeat imaging or prolonged observation is not necessary if initial CT is negative and patient remains neurologically unchanged. 1
• Delayed intracranial hemorrhage occurs in only 0.6% of warfarin patients and 0% of clopidogrel patients with initially negative CT. 1
• Provide discharge instructions about rare delayed hemorrhage symptoms and consider outpatient fall risk assessment and anticoagulation risk-benefit review. 1

Important caveat: This recommendation applies specifically to warfarin and clopidogrel; insufficient data exists for aspirin alone or newer agents, so clinical judgment should guide management in these cases. 1

Elderly Patients

• Male sex, consciousness impairment, focal neurological deficit, prior traumatic brain injury history, and time interval >5 hours between trauma and CT are associated with higher likelihood of traumatic lesions. 5
• Anticoagulant therapy alone does not significantly increase risk of traumatic lesions in elderly fallers. 5

Neurosurgical Consultation and Intervention

Mandatory Immediate Consultation

• Obtain urgent neurosurgical consultation for any patient with history of lucid interval, even if currently stable, and for all abnormal CT findings. 2, 3

Surgical Indications

• Epidural hematoma with mass effect 1, 2, 3
• Acute subdural hematoma >5 mm thickness with midline shift >5 mm 1
• Depressed skull fractures, particularly if open with CSF leak or brain tissue exposure 2, 3, 4
• Any expanding intracranial lesion causing significant mass effect or midline shift 2, 3
• Acute hydrocephalus requiring drainage 1

Intracranial Pressure Management

ICP Monitoring Indications

• Implement ICP monitoring in severe TBI (GCS ≤8) with abnormal CT findings. 1, 3, 4
• Consider ICP monitoring in moderate TBI (GCS 9-13) with history of lucid interval or high-risk CT findings. 2, 3
• Target ICP <20 mmHg and maintain cerebral perfusion pressure (CPP) ≥60 mmHg when monitoring available. 3, 4

Tiered ICP Management Approach

First-tier interventions:

• Adequate sedation and analgesia (avoid bolus dosing of midazolam or opioids that cause hypotension) 1
• Maintain normothermia 3
• Treat seizures promptly with benzodiazepines and levetiracetam 1, 3
• Elevate head of bed 30 degrees 2
• Maintain normocapnia (avoid hyperventilation except briefly for herniation) 1

Second-tier interventions for refractory intracranial hypertension:

• External ventricular drainage (EVD) for CSF diversion—even small volumes can significantly reduce ICP 1
• Osmotic therapy with mannitol 20% (0.25-2 g/kg) or hypertonic saline for clinical deterioration 1, 3
• Decompressive craniectomy (large temporal >100 cm² with dural expansion) in multidisciplinary discussion for refractory cases 1

Critical Pitfalls to Avoid

• Never delay neuroimaging in patients with lucid interval history, even if currently appearing well—deterioration can be sudden and catastrophic. 2, 4
• Never use hypotonic fluids—use 0.9% saline to avoid worsening cerebral edema. 1, 2, 4
• Never employ prolonged hyperventilation—brief periods (PaCO2 4.0-4.5 kPa) only acceptable for impending uncal herniation. 1, 4
• Never attribute decreased consciousness or focal deficits to seizure activity alone in patients with seizure-related falls—these patients have 90.9% incidence of intracranial hematomas requiring CT exclusion. 6
• Never assume stability based on current presentation—patients with head injuries from falls, particularly elderly patients and those with lucid intervals, require close monitoring for delayed deterioration. 2, 5

Transfer Considerations for Severe TBI

Pre-transfer Requirements

• Secure airway with appropriate sedation (high-dose fentanyl 3-5 µg/kg or remifentanil TCI, induction agent maintaining MAP, neuromuscular blockade) 1
• Establish invasive arterial monitoring with transducer at tragus level when possible 1
• Ensure availability of resuscitation drugs, mannitol/hypertonic saline, vasopressors, anticonvulsants, and cross-matched blood if trauma patient 1
• Maintain target blood pressures and oxygenation parameters throughout transfer 1