What is the recommended assessment, imaging indications, and initial medical management for an adult patient with a traumatic head injury?

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Head Injury Management in Adults

Initial Clinical Assessment

All adult patients with traumatic head injury require immediate evaluation using the Glasgow Coma Scale (GCS), with particular attention to the motor component as it remains the most robust indicator, especially in intubated or sedated patients. 1

Severity Stratification by GCS

  • Severe TBI (GCS ≤8): Requires immediate aggressive management with continuous monitoring 2
  • Moderate TBI (GCS 9-13): Necessitates structured observation and serial assessments 2
  • Mild TBI (GCS 14-15): Requires risk-stratified approach based on additional clinical features 2

Critical Secondary Insult Detection

Immediately identify and correct arterial hypotension (systolic BP <90 mmHg) and hypoxemia (SaO₂ <90%), as their combination carries a 75% mortality rate. 2

  • Maintain mean arterial pressure ≥80 mmHg in all severe TBI patients 2
  • Ensure oxygen saturation >95% to prevent secondary brain injury 3
  • The presence of even brief hypotensive episodes (≥5 minutes) significantly increases morbidity and mortality 2

Imaging Indications

Mandatory CT Imaging

Perform brain and cervical CT scan immediately and without delay in the following patients: 2

Severe and Moderate TBI

  • All patients with GCS ≤13 require immediate CT imaging 2

Mild TBI (GCS 14-15) with ANY of:

  • Signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, Battle's sign, raccoon eyes) 2
  • Displaced skull fracture 2
  • Post-traumatic seizure 2
  • Focal neurological deficit 2
  • Coagulation disorders 2
  • Any anticoagulant therapy (warfarin, NOACs including apixaban, rivaroxaban, dabigatran) 2, 4
  • Antiplatelet agents (clopidogrel, ticagrelor—excluding aspirin alone) 2, 4
  • Age >60-65 years 4
  • Vomiting (especially if more than once) 4
  • Loss of consciousness or post-traumatic amnesia 4
  • Dangerous mechanism (pedestrian struck, fall from height, high-speed collision) 4

Special Consideration: Anticoagulated Patients

All patients on anticoagulants or antiplatelet agents require immediate CT imaging after any head trauma, regardless of how minor the mechanism appears. 2, 4

  • Warfarin patients have 3.9% ICH risk vs 1.5% in non-anticoagulated patients 4
  • NOACs carry 2.6% ICH rate vs 10.2% for vitamin K antagonists 4
  • Bleeding progression occurs in 26% of anticoagulated patients vs 9% of non-anticoagulated 4
  • Delayed ICH risk ranges 0.6-6% even with initially normal presentation 2, 4

Repeat Imaging Indications

Obtain immediate repeat CT scan for: 2, 1

  • Decrease of ≥2 points in GCS score 2, 1
  • Any new neurological deficit 1
  • Secondary neurological deterioration 2

For patients with positive initial CT, perform follow-up imaging at approximately 6 and 24 hours to assess for hemorrhage expansion, which occurs most commonly within the first 6 hours. 1

Neurological Monitoring Protocol

Severe TBI (GCS ≤8)

Perform hourly neurological examinations until patient achieves GCS 15, with documentation required on a half-hourly basis. 1

  • Continue hourly assessments, understanding that prolonged checks beyond 48-72 hours may cause harm through sleep deprivation 1
  • Document individual GCS components (Eye, Motor, Verbal) rather than sum scores alone 3
  • Assess pupillary size and reactivity at each evaluation 3

Moderate TBI (GCS 9-13)

Perform neurological checks every 30 minutes for the first 2 hours, then hourly for the following 4 hours. 1

Mild TBI with Positive CT

Monitor with serial neurological assessments, with frequency determined by specific findings and risk factors. 1

Prehospital and Transfer Management

Severe TBI patients must be managed by a prehospital medicalized team on scene and transferred as soon as possible to a specialized center with neurosurgical facilities. 2

  • Management in specialized neuro-intensive care units is associated with improved outcomes and reduced mortality 2
  • Non-specialized centers should rapidly identify patients requiring transfer 2
  • Expertise from large patient volumes and neurosurgeon availability improves outcomes even for patients not requiring surgery 2

Adjunctive Assessment Tools

Transcranial Doppler (TCD)

Consider using TCD on arrival to assess severity and guide early management decisions. 2

  • Diastolic velocity <20 cm/s and Pulsatility Index >1.4 in severe TBI warrant immediate measures to improve brain perfusion 2
  • Mean blood flow velocity <28 cm/s or combination of low velocity and high PI associated with higher mortality 2
  • For moderate/mild TBI: diastolic velocity <25 cm/s or PI >1.25 predicts secondary neurological degradation 2
  • TCD should be incorporated into FAST examination for multiple trauma patients 2

Biomarkers

Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) in clinical routine for initial severity assessment, as uncertainties remain regarding normal ranges and clinical utility. 2

Disposition Decisions

Mandatory Admission

Admit all patients with: 3

  • Any documented intracranial hemorrhage on CT, regardless of GCS 3
  • GCS <15 at 2 hours post-injury 4
  • Subdural hematoma, even with normal neurological examination, due to delayed deterioration risk 3

Anticoagulated Patients with Negative Initial CT

Brief observation of 4-6 hours is reasonable before discharge if neurologically intact; routine admission is not necessary. 1

  • However, delayed ICH remains possible (0.6% in warfarin patients, though rare in clopidogrel patients) 2
  • Provide clear return precautions for new or worsening symptoms 4

Critical Pitfalls to Avoid

  • Never delay CT imaging in anticoagulated patients, even with minor mechanisms 1
  • Never delay repeat imaging when neurological deterioration occurs, regardless of time since initial scan 1
  • Never administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 3
  • Never rely on a single GCS assessment—serial assessments provide substantially more valuable clinical information 3
  • Never delay correction of hypotension and hypoxia while waiting to prognosticate 3
  • Never discharge patients with documented subdural hematoma, even with normal examinations 3

Specific Management Considerations

Intubation Decisions

Do not routinely intubate all patients with GCS 7-8 and isolated head injury, as immediate intubation is independently associated with higher mortality and complications. 5

  • Consider intubating patients <45 years with head AIS score of 5 and GCS score of 7 5
  • Assess airway protection capability before reflexive intubation 3
  • ICU admission with intubation is premature for GCS 14 patients who can protect their airway unless herniation signs present 3

Elderly Patients

Age alone should not limit treatment decisions; assess frailty as a superior predictor of poor outcome. 3

  • Patients not showing improvement within 72 hours require careful evaluation before further aggressive treatment 3
  • Neurological status at 72 hours is a good prognostic factor for in-hospital death but not for long-term outcomes 3

References

1
Guideline

Neurological Assessment Frequency After Head Injury

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

Management of Elderly Patients with Subdural Hematoma

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Head Injury Evaluation and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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