Should a patient with head trauma be allowed to sleep?

Should a Patient with Head Trauma Be Allowed to Sleep?

Yes, patients with head trauma should be allowed to sleep, but only after appropriate initial assessment and with a structured protocol for serial neurological monitoring during their observation period. The outdated practice of preventing sleep to "watch for deterioration" is not evidence-based and can actually harm patients by causing unnecessary distress and interfering with recovery.

The Evidence-Based Approach to Observation

Initial Assessment Requirements

Before allowing sleep, patients require:

• Complete neurological evaluation using the Glasgow Coma Scale (GCS), specifically documenting all three components (Eye-Verbal-Motor response) and pupillary size and reactivity 1
• Brain CT scan performed systematically and without delay for any patient with GCS ≤13 or concerning clinical features 1
• Correction of secondary insults including hypotension (maintain mean arterial pressure ≥80 mmHg) and hypoxemia (maintain SaO2 >95%) 1

Structured Serial Monitoring Protocol

The key is not preventing sleep, but implementing frequent serial assessments:

• First 2 hours: Neurological examination every 15 minutes (Scandinavian protocol) or every 30 minutes (UK protocol) 1, 2
• Hours 2-12: Neurological examination every hour 1
• Beyond 12 hours: Continue hourly assessments as clinically indicated 1

This approach allows patients to rest between assessments while ensuring rapid detection of deterioration. Serial GCS assessments provide substantially more valuable clinical information than a single determination or continuous wakefulness 2.

Critical Thresholds for Intervention

Patients can sleep with monitoring, but require immediate action if:

• GCS decreases by ≥2 points from baseline, warranting immediate repeat CT scan 1, 2
• Development of new focal neurological deficits indicating mass effect 2
• Pupillary changes suggesting herniation 2

Risk Stratification Determines Monitoring Intensity

Moderate TBI (GCS 9-13)

These patients have significant risk of secondary neurological degradation and require the intensive monitoring protocols described above 1. Sleep is permitted but with frequent awakening for assessment.

Mild TBI (GCS 14-15) with Abnormal CT

Approximately 1 in 4 will require treatment, so admission with serial monitoring is mandatory even if initially stable 2. These patients can sleep with less frequent (but still regular) neurological checks.

Mild TBI with Normal CT

Even with normal imaging, discharge is contraindicated for patients with subdural hematomas due to risk of delayed deterioration 2. However, patients with truly minor injuries and normal scans may be observed with less intensive protocols.

Common Pitfalls to Avoid

• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 2
• Do not delay correction of hypotension and hypoxemia while performing serial assessments—physiological stability takes priority 3
• Do not make irreversible treatment decisions before 72 hours unless brain death criteria are met or clear clinical deterioration occurs 2, 3
• Do not rely on a single GCS assessment—approximately 13% of patients who became comatose had an initial GCS of 15, illustrating the inadequacy of single evaluations 2

The Rationale: Why Sleep Is Permitted

The guideline evidence emphasizes repeated clinical examination rather than continuous wakefulness 1. The critical factor is detecting secondary neurological aggravation through serial assessments, not preventing sleep itself. Patients with moderate TBI can be safely monitored with examinations every 15-60 minutes depending on severity and time from injury 1.

Preventing sleep causes patient distress, interferes with recovery, and provides no additional safety benefit compared to structured serial monitoring protocols. The focus should be on maintaining physiological homeostasis (adequate blood pressure, oxygenation, normocapnia) and detecting deterioration early through frequent assessments 1.