What are the guidelines for managing a patient with a significant head injury?

Management of Significant Head Injury

Immediately control life-threatening hemorrhage first, then perform urgent neurological evaluation (Glasgow Coma Scale motor score and pupils) with brain CT scan, followed by neurosurgical consultation for any salvageable patient with life-threatening brain lesions. 1

Initial Resuscitation Priorities

Airway and Breathing Management

• Intubate immediately if GCS ≤8, deteriorating consciousness, or inability to maintain adequate oxygenation 2
• Maintain PaO₂ between 60-100 mmHg (or oxygen saturation ≥95%) to prevent hypoxemia, which dramatically worsens outcomes 1, 2
• Target PaCO₂ between 35-40 mmHg (normocapnia) during all interventions 1, 2
• Monitor end-tidal CO₂ continuously in intubated patients 2

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg at all times 1, 3, 2
• Even a single episode of hypotension (SBP <90 mmHg) significantly increases mortality and morbidity 1, 3
• In polytrauma patients with life-threatening hemorrhage, lower blood pressure values may be tolerated briefly during bleeding control, but restore immediately afterward 1

Cervical Spine Protection

• Assume cervical spine injury in all unconscious head trauma patients until proven otherwise 3, 2
• Maintain full spinal immobilization during initial management 3

Hemorrhage Control in Polytrauma

For patients with exsanguinating hemorrhage, immediate surgical or interventional radiology intervention for bleeding control takes absolute priority 1

• After hemorrhage control is established, proceed immediately to neurological evaluation 1
• Balance between treating systemic hemorrhage and preventing secondary brain injury by maintaining the blood pressure targets above 1

Neurological Assessment

Clinical Evaluation

• Assess severity using Glasgow Coma Scale, specifically the motor response component, plus pupillary size and reactivity bilaterally 1, 3
• The motor component remains the most robust indicator in sedated patients 1
• Abnormal pupils indicate severe injury and poor prognosis 3, 4
• Repeat neurological examination frequently to detect secondary deterioration 1

Imaging Strategy

• Obtain urgent non-contrast brain CT scan immediately in all patients with GCS ≤13, any loss of consciousness, post-traumatic amnesia, focal deficits, or anticoagulant use 1, 3, 2
• Do not delay CT imaging—this must occur immediately upon arrival 3, 2
• Include cervical spine CT in all severe head trauma patients 2

Neurosurgical Intervention

Immediate Consultation Indications

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after hemorrhage control 1, 3
• Epidural hematoma with mass effect 3, 4, 2
• Acute subdural hematoma >5mm thickness with midline shift >5mm 2
• Depressed skull fractures 4, 2
• Any expanding intracranial lesion causing significant mass effect or midline shift 4, 2

Critical "Red Flags" Requiring Immediate Action

• Persistent altered mental status or worsening level of consciousness 3
• Severe or progressively worsening headache 3
• Repeated vomiting 3
• Seizure activity 3
• Focal neurological deficits 3
• Signs of cerebral herniation (pupillary abnormalities, posturing) 3

Intracranial Pressure Monitoring

Patients in coma with radiological signs of intracranial hypertension require ICP monitoring regardless of need for other emergency surgeries 1, 3, 4

• This applies to patients at risk for elevated ICP even without a mass lesion requiring immediate evacuation 1, 3
• Target ICP <20 mmHg 4, 2
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 4, 2

Management of Elevated Intracranial Pressure

First-Tier Interventions

• Ensure adequate sedation and analgesia 4, 2
• Maintain normothermia 4, 2
• Treat seizures promptly 4, 2
• Elevate head of bed to 30 degrees to improve venous drainage 4, 2
• Maintain normocapnia (PaCO₂ 35-40 mmHg) 1, 4, 2

Second-Tier Interventions for Clinical Deterioration

• In cases of cerebral herniation or impending uncal herniation, use osmotherapy (mannitol 0.25-2 g/kg) and/or brief hyperventilation temporarily 1, 4
• Hyperventilation should only be used briefly (PaCO₂ 4.0-4.5 kPa) for impending herniation, as prolonged use causes cerebral ischemia 2

Coagulation Management

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage interventions 1
• For emergency neurosurgery (including ICP probe insertion), higher platelet values are advisable 1
• Maintain prothrombin time/aPTT <1.5 times normal control during all interventions 1

Transfusion Thresholds

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• Higher thresholds may be used in elderly patients or those with limited cardiovascular reserve 1

Critical Pitfalls to Avoid

Imaging Delays

• Never delay CT imaging in patients with loss of consciousness or lucid interval history, even if currently appearing stable 3, 4, 2
• Deterioration can be sudden and catastrophic 4, 2

Hypotension and Hypoxia

• Never allow hypotension or hypoxia—these are the most preventable causes of secondary brain injury 1, 3
• The combination of hypotension and hypoxemia carries a 75% mortality rate 1

Fluid Management

• Never use hypotonic fluids—use 0.9% saline exclusively to avoid worsening cerebral edema 4, 2

Hyperventilation Misuse

• Never employ prolonged hyperventilation as routine therapy—it causes cerebral ischemia 4, 2
• Reserve brief hyperventilation only for impending herniation while awaiting definitive neurosurgical intervention 1, 4

Clinical Assumptions

• Never rely on clinical examination alone to rule out intracranial injury when loss of consciousness has occurred 3
• Never assume a patient who appears stable will remain so—patients with lucid intervals can deteriorate suddenly 4

Transport Considerations

• Transport immediately to a specialized trauma center with neurosurgical capabilities 3
• Outcomes are significantly better when severe traumatic brain injury patients are managed at centers with neurosurgical expertise 3
• Consider air ambulance evacuation if ground transport time is prolonged 5