What is the initial management of a patient with head trauma and a small left periorbital laceration?

Initial Management of Head Trauma with Small Left Periorbital Laceration

Immediately assess for signs of serious intracranial injury and orbital complications, as periorbital hematoma is a red flag for basilar skull fracture requiring urgent CT imaging, even in patients with mild traumatic brain injury. 1

Primary Survey and Severity Assessment

Assess Glasgow Coma Scale (GCS) immediately, focusing on motor response, pupillary size, and reactivity to classify severity: severe (GCS ≤8), moderate (GCS 9-13), or mild (GCS 14-15). 1

Document critical history elements including mechanism of injury, any loss of consciousness, presence of lucid interval, vomiting, seizure activity, and anticoagulant use. 1, 2

Evaluate for secondary brain injury factors:

• Maintain systolic blood pressure ≥100 mmHg (or >110 mmHg in severe cases), as hypotension dramatically worsens neurological outcomes and increases mortality. 1
• Ensure adequate oxygenation with SaO2 >90%, as hypoxemia occurs in 20% of TBI patients and is associated with 75% mortality when combined with hypotension. 1
• Maintain normocapnia with PaCO2 35-40 mmHg or EtCO2 30-35 mmHg initially. 1

Orbital and Ocular Examination

Perform systematic non-contact examination first to assess ocular integrity before any manipulation, as periorbital trauma carries high risk of occult ocular complications. 3

Evaluate specifically for:

• Visual acuity and visual field defects, which suggest globe or optic nerve injury. 1
• Extraocular movements and diplopia, which may indicate orbital fracture with muscle entrapment or nerve injury. 1
• Pupillary examination for size, symmetry, and reactivity. 1
• Globe integrity, looking for penetrating injury or rupture. 1
• Intraocular pressure if globe is intact. 3
• Lacrimal drainage system involvement, particularly with medial canthal lacerations. 4

Neuroimaging Decision

Obtain urgent non-contrast CT scan of head and orbits if ANY of the following are present:

• Periorbital hematoma (sign of basilar skull fracture). 1
• GCS ≤13. 1
• Loss of consciousness or altered mental status. 1
• Post-traumatic seizure. 1
• Focal neurological deficit. 1
• Vomiting. 1
• Coagulation disorders or anticoagulant therapy. 1
• Suspected orbital fracture, foreign body, or globe injury. 1

CT orbits is the most accurate imaging modality for detecting orbital fractures (94.9% sensitive for foreign bodies) and evaluating soft tissue injuries including globe rupture and extraocular muscle damage. 1

CT head should be obtained concurrently when intracranial injury or calvarial fracture is suspected, particularly with periorbital hematoma suggesting basilar skull fracture. 1

Laceration Management

Delay definitive laceration repair until ocular status is fully established to avoid increasing ocular damage during reconstruction. 3

Control active bleeding with direct pressure; avoid blind clamping which may damage underlying structures. 4

Examine wound carefully for:

• Depth and involvement of deeper structures (orbital septum, levator, tarsal plate). 4, 5
• Lacrimal system injury, particularly with medial canthal involvement. 4
• Foreign bodies, which may be occult on clinical examination alone. 6
• Fat prolapse suggesting orbital septum violation. 4

Obtain immediate ophthalmology consultation for any concern of globe injury, lacrimal system involvement, or complex eyelid injury requiring specialized repair. 3, 4

Neurosurgical Consultation Triggers

Contact neurosurgery immediately if:

• History of lucid interval, even if currently stable, as these patients are at high risk for expanding intracranial lesions. 2
• GCS ≤8 with abnormal CT findings. 1
• Depressed or open skull fractures. 1, 2
• Any expanding intracranial lesion with mass effect. 2
• Epidural hematoma. 2

Critical Pitfalls to Avoid

Never delay neuroimaging in patients with periorbital hematoma, as this is a clinical sign of basilar skull fracture requiring CT even with GCS 14-15. 1

Never use hypotonic solutions like Ringer's lactate in head trauma patients, as these worsen cerebral edema. 1

Never allow hypotension in TBI patients, even when managing hemorrhagic shock elsewhere—maintain MAP ≥80 mmHg. 1

Never assume stability in patients who appear well initially, as deterioration can be sudden, particularly with lucid interval history. 2

Never perform definitive laceration repair before establishing ocular integrity and ruling out serious orbital/intracranial injury. 3

Never miss lacrimal system injuries in medial canthal lacerations, as these are difficult to detect and repair secondarily. 4

Disposition and Monitoring

Admit for observation any patient with:

• Abnormal CT findings. 1
• GCS <15 that doesn't normalize. 1
• Persistent symptoms despite normal CT. 1
• Unreliable home monitoring situation. 1

Perform serial neurological examinations every 15 minutes for 2 hours, then hourly for 4-12 hours depending on severity. 1

Repeat CT scan if neurological deterioration occurs or GCS drops ≥2 points. 1