What is the immediate management of an unconscious adult or adolescent with a traumatic head injury and no known comorbidities?

Initial Management of Unconscious Head Injury

An unconscious patient with traumatic head injury requires immediate airway protection with cervical spine immobilization, aggressive hemodynamic resuscitation targeting systolic blood pressure >110 mmHg, urgent non-contrast head CT scanning, and immediate neurosurgical consultation. 1, 2

Immediate Resuscitation (ABCDE Sequence)

Airway & Cervical Spine

• Establish and maintain a patent airway while maintaining complete cervical spine immobilization with full spinal immobilization, as cervical spine injuries commonly accompany head injuries 3, 4
• Intubate all comatose patients (GCS ≤8) to protect against aspiration, as vomiting and seizures are common with rising intracranial pressure 1, 4
• Avoid long-acting sedatives or paralytics before neurosurgical evaluation, as these mask clinical deterioration 1

Breathing & Ventilation

• Maintain PaO2 between 60-100 mmHg to ensure adequate oxygenation without hyperoxia 1
• Target PaCO2 between 35-40 mmHg (normocapnia) during all interventions 1
• Reserve temporary hyperventilation (hypocapnia) only for cases of cerebral herniation while awaiting emergency neurosurgery, as excessive hyperventilation causes cerebral vasoconstriction and may worsen cerebral perfusion 1, 4

Circulation & Hemodynamics

• Maintain systolic blood pressure >110 mmHg at all times to prevent secondary brain injury and reduce mortality 2
• If hypotension develops, use vasopressors (phenylephrine or norepinephrine) immediately rather than waiting for fluid resuscitation effects 2
• Alternative targets: maintain systolic BP >100 mmHg or mean arterial pressure >80 mmHg during acute phase 1
• After ICP monitor placement, target cerebral perfusion pressure (CPP) between 60-70 mmHg 1
• Avoid CPP >70 mmHg routinely, as CPP >90 mmHg worsens neurological outcomes due to vasogenic cerebral edema 1

Disability & Neurological Assessment

• Document Glasgow Coma Scale (GCS) with individual components (Eye, Motor, Verbal) and pupillary size/reactivity 1
• Assess for signs of increased intracranial pressure and impending cerebral herniation 3
• Monitor for Cushing's triad (bradycardia, hypertension, irregular respirations) indicating medullary compression 4
• Distinguish posturing patterns: decorticate (arms flexed upward) versus decerebrate (arms extended downward), with decerebrate indicating deeper brainstem involvement 4

Exposure & Temperature

• Expose patient fully while preventing hypothermia 3

Urgent Diagnostic Imaging

Non-Contrast Head CT

• All unconscious head injury patients require urgent non-contrast head CT scanning immediately after initial stabilization 5, 6
• CT scanning takes priority over plain skull radiographs, which are poor indicators of intracranial abnormalities 5
• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 1
• Repeat CT scanning is necessary for any patient with GCS decline of ≥2 points 1

Additional Imaging Considerations

• Consider CT angiography of supra-aortic and intracranial vessels if basal skull fracture, focal neurological findings, or vascular injury suspected 2

Anticoagulation Management

• Immediately determine if patient is taking any anticoagulant or antiplatelet agents, as this is vital for management 2
• Hold aspirin immediately, as elderly patients (≥65 years) on aspirin have 3-fold increased risk of hemorrhage progression 1
• Reverse anticoagulation immediately if patient is on warfarin, NOACs, or antiplatelet agents 1
• Maintain platelet count >50,000/mm³ for systemic hemorrhage control 1
• Maintain PT/aPTT <1.5 times normal control during all interventions 1
• Transfuse red blood cells for hemoglobin <7 g/dL 1

Intracranial Pressure Management

ICP Monitoring

• All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension require ICP monitoring regardless of whether they undergo emergency neurosurgery 1
• Intraparenchymal probes are preferred over ventricular catheters due to better risk-benefit profile 1

Medical Management of Elevated ICP

• Use osmotherapy (mannitol) and/or temporary hypocapnia while awaiting emergency neurosurgery in cases of cerebral herniation 1
• Do not use corticosteroids (such as dexamethasone) for traumatic brain injury management, as they may worsen outcomes 1

Neurosurgical Consultation & Admission

Immediate Neurosurgical Consultation Required For:

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation after control of life-threatening hemorrhage 1
• Development of pupillary changes or posturing indicating herniation 1
• GCS decline of ≥2 points 1
• Development of focal neurological deficits indicating mass effect 1
• Midline shift >5 mm with low GCS scores 1
• Subdural hematoma thickness >5 mm with midline shift >5 mm 1

Admission Requirements

• All unconscious head injury patients require admission to neurosurgical intensive care unit with continuous neurological assessment 2
• Surgical evacuation should be performed as soon as possible after decision is made, as delaying surgery in patients with significant midline shift and low GCS scores is associated with poorer outcomes 1

Neurological Monitoring Protocol

Serial Assessments

• Monitor GCS every 15 minutes for the first 2 hours, then hourly for the following 12 hours 1
• Document individual GCS components and pupillary size/reactivity at each evaluation 1
• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning 1
• Serial CT scans are necessary in almost half of moderate-to-severe head injury patients, with 32% showing progression of radiological abnormalities 5

Critical Pitfalls to Avoid

• Do not delay transfer for "medical optimization" beyond basic resuscitation in patients requiring neurosurgical intervention, as this is a time-critical emergency 1
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation 1
• Do not fail to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1
• Do not delay correction of secondary insults (hypotension, hypoxia) while monitoring 1
• Do not over-hyperventilate, as excessive reduction in PaCO2 causes cerebral vasoconstriction and may worsen cerebral anoxia 4
• Do not assume absence of skull fracture excludes intracranial injury, as skull fractures are poor indicators of intracranial abnormalities 5