What is the appropriate management for a patient with head trauma, considering their medical history and potential complications?

Management of Head Trauma

The management of head trauma must be stratified by severity using the Glasgow Coma Scale (GCS), with immediate airway control, blood pressure maintenance >110 mmHg, and urgent CT imaging forming the foundation of care for moderate-to-severe injuries, while mild injuries require selective CT scanning based on validated clinical decision rules. 1, 2

Initial Assessment and Stabilization

Airway Management

• Establish airway control as the absolute priority through endotracheal intubation and mechanical ventilation for all severe TBI patients (GCS ≤8), beginning in the pre-hospital period. 2, 3
• Monitor end-tidal CO2 continuously to maintain PaCO2 within normal range (35-40 mmHg), as hypocapnia induces cerebral vasoconstriction and risks brain ischemia. 2, 3
• Confirm correct endotracheal tube placement through continuous EtCO2 monitoring. 2
• Avoid routine hyperventilation, as it decreases cerebral perfusion and worsens outcomes—use only transiently for signs of imminent herniation. 1

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome. 2, 3
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation, as fluids have delayed hemodynamic effects. 2, 3
• Avoid hypotensive sedative agents; use continuous infusions instead of boluses to prevent hemodynamic instability. 2

Severity Classification

The GCS score determines management pathways: 1

• Severe (GCS 3-8): Requires immediate intubation, ICP monitoring, and neurosurgical consultation
• Moderate (GCS 9-12): Requires CT imaging and close observation
• Mild (GCS 13-15): Requires selective CT based on clinical decision rules

Imaging Strategy

Mild Head Trauma (GCS 13-15)

Use validated clinical decision rules to determine CT necessity, as only 10% will have positive findings and only 1% require neurosurgical intervention. 1

Canadian CT Head Rule (CCHR) - High-Risk Factors

CT is indicated if ANY of the following are present: 1

• Failure to reach GCS 15 within 2 hours
• Suspected open skull fracture
• Signs of basal skull fracture (hemotympanum, raccoon eyes, Battle's sign, CSF leak)
• Vomiting more than once
• Age >64 years

Medium-Risk Factors (CCHR)

CT is indicated for clinically important brain injury if: 1

• Post-traumatic amnesia >30 minutes
• Dangerous mechanism (pedestrian struck, ejection from vehicle, fall >3 feet or 5 stairs)

Moderate-to-Severe Head Trauma

• Obtain non-contrast CT of brain and cervical spine immediately without delay to guide neurosurgical procedures. 2, 3
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (CNS and bone). 2, 3

Neurosurgical Intervention Criteria

Surgical evacuation is indicated for: 2, 3

• Symptomatic epidural hematoma (regardless of size)
• Acute subdural hematoma with thickness >5mm or midline shift >5mm
• Brain contusions with significant mass effect
• Acute hydrocephalus requiring drainage
• Open or closed displaced skull fracture with brain compression

Intracranial Pressure Management

ICP Monitoring

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy. 2
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available. 2
• Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension. 2

Medical Management of Elevated ICP

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 2, 3
• Use propofol by continuous infusion (not bolus) in combination with mild hypocapnia to decrease ICP. 2
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal function. 2, 3

Supportive Care Measures

Coagulation Management

• Maintain platelet count >100,000/mm³, as coagulopathy worsens intracranial bleeding progression. 2
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio if needed, then modify based on laboratory values. 2

Seizure Prophylaxis

• Implement detection and prevention strategies for post-traumatic seizures. 2, 3

Ventilation Strategy

• Increasing PEEP from 0 to 5-15 cm H₂O is associated with decreased ICP and improved cerebral perfusion pressure. 2

Critical Pitfalls to Avoid

These errors significantly worsen outcomes: 2, 3

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors
• Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility
• Never hyperventilate routinely, as it restricts cerebral perfusion 1

Disposition and Follow-Up

Mild Head Trauma with Negative CT

• Patients with normal CT and improving clinical status can be discharged with detailed warning instructions to caregivers. 1
• Ensure reliable observers are available and provide specific return precautions. 1

Moderate-to-Severe Head Trauma

• Transfer immediately to a trauma center with neurosurgical capabilities—do not delay for stabilization at non-specialized facilities. 2, 3
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes and communication without reducing survival. 2