What is the emergent evaluation and management for a patient with head trauma presenting with altered mental status?

Emergent Evaluation and Management of Head Trauma with Disorientation

All patients with head trauma presenting with altered mental status require immediate non-contrast head CT scanning and urgent neurological evaluation, as disorientation represents a high-risk criterion for clinically important brain injury requiring hospital admission. 1

Immediate Assessment and Stabilization

Primary Survey

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg throughout all interventions, as hypotension worsens secondary brain injury and mortality 1, 2, 3
• Ensure adequate oxygenation with PaO₂ between 60-100 mmHg 1, 2
• Target normocapnia with PaCO₂ between 35-40 mmHg; reserve temporary hyperventilation only for impending herniation while awaiting neurosurgery 1, 2

Urgent Neurological Evaluation

Perform immediate assessment including: 1, 2

• Pupillary examination (size and reactivity bilaterally)
• Glasgow Coma Scale with individual component documentation (Eye, Motor, Verbal scores)
• Focal neurological deficits
• Signs of basilar skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea)

Emergent Neuroimaging

Indications for Immediate CT Head

Disorientation alone mandates emergent CT scanning based on validated clinical decision rules 1:

The Canadian CT Head Rule identifies disorientation as a high-risk factor with 100% sensitivity for predicting need for neurosurgical intervention when combined with: 1

• Failure to reach GCS 15 within 2 hours
• Suspected open or depressed skull fracture
• Signs of basilar skull fracture
• Vomiting ≥2 episodes
• Age >64 years

All patients with altered mental status from head trauma require CT imaging regardless of other factors, as this population has a 4.3-4.4% risk of clinically important intracranial injury 1, 4

Timing

• Obtain non-contrast head CT immediately upon ED arrival without delay for laboratory results if patient is hemodynamically stable for transport 5
• CT has excellent sensitivity for acute hemorrhage, skull fractures, and mass lesions requiring neurosurgical intervention 1, 5

Hospital Admission Criteria

All patients with documented intracranial injury on CT require admission regardless of subsequent neurological improvement, as delayed deterioration can occur even in initially stable patients 2

Monitoring Protocol During Admission

• GCS assessment every 15 minutes for first 2 hours, then hourly for 12 hours 2
• Document individual GCS components and pupillary findings at each evaluation 2
• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within first 6 hours 2
• Any GCS decline ≥2 points warrants immediate repeat CT scanning 2

Anticoagulation Management

If patient is on anticoagulants or antiplatelet agents: 2

• Hold aspirin immediately (elderly patients ≥65 years on aspirin have 3-fold increased hemorrhage progression risk)
• Reverse warfarin, NOACs, or other anticoagulants emergently
• Maintain platelet count >50,000/mm³ for hemorrhage control 1, 2
• Maintain PT/aPTT <1.5 times normal control 1, 2

Neurosurgical Consultation Triggers

Obtain urgent neurosurgical consultation for: 1, 2, 3

• Any life-threatening brain lesion on CT (subdural hematoma, epidural hematoma, large contusion with mass effect)
• GCS ≤8 (comatose patients)
• Pupillary changes or posturing indicating herniation
• GCS decline ≥2 points
• Development of focal neurological deficits
• Midline shift >5 mm
• Subdural or epidural hematoma thickness >5 mm with midline shift

ICP Monitoring Indications

All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension require ICP monitoring regardless of whether they undergo emergency neurosurgery 1, 2

• Target cerebral perfusion pressure 60-70 mmHg after monitor placement 2
• Intraparenchymal probes preferred over ventricular catheters 2

Critical Pitfalls to Avoid

• Do not discharge patients with altered mental status after head trauma without CT imaging, even if they subsequently normalize, as 12% of patients with "therapeutically inconsequential" CT findings have important neurosurgical outcomes 4
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 2
• Do not delay CT imaging for "observation" in patients with disorientation—this is a validated high-risk criterion requiring immediate imaging 1
• Do not rely on normal vital signs to exclude significant injury, especially in elderly patients or those on anticoagulants 1, 2
• Do not discharge patients with documented intracranial findings based solely on normal repeat neurological examination, as delayed deterioration requiring neurosurgery can occur 2

Special Populations

Elderly Patients (>64 years)

• Age >64 years is an independent high-risk factor for neurosurgical intervention 1
• Lower threshold for admission even with minimal CT findings 1

Patients on Anticoagulation

• Even with normal initial CT, second CT at 24 hours is recommended before discharge in anticoagulated patients, though evidence for single CT discharge safety is emerging 1
• Higher transfusion thresholds may be appropriate (hemoglobin <7 g/dL minimum) 1, 2