C H A P T E R 7 HEAD TRAUMA I. GLASGOW COMA SCALE (GCS) A. Eye opening—none (1), to pain (2), to voice (3), spontaneously (4) B. Verbal output—none (1), sounds (2), words (3), disoriented (4), oriented (5) C. Motor function—none (1), extensor posturing (2), flexor posturing (3), withdrawal from pain (4), localizing (5), following commands (6) II. HEAD TRAUMA GRADING—severe (GCS 3–8), moderate (GCS 9–12), mild (GCS 13–15) III. GOOD OUTCOMES—GCS 3–6 (8%), 7–8 (41%), 9–12 (81%) A. Outcome worse if SBP < 90 mm Hg or pO2 < 60 mm Hg IV. INTRACRANIAL PRESSURE (ICP) MONITOR—place if GCS < 9 with an abnormal computed tomography (CT) scan V. CEREBRAL PERFUSION PRESSURE—maintain > 70; try to keep ICP < 20 mm Hg VI. ICP CONTROL A. Cerebrospinal fluid (CSF) drainage B. Mannitol—1 g/kg bolus and 0.25 g/kg every 6 hours (q6h) 1. Check serum osmolarity q6h and hold mannitol if < 320 to avoid acute tubular necrosis 2. Maintain euvolemia and normokalemia 3. Avoid mannitol with congestive heart failure or renal failure C. Sedation and paralytics D. Pentobarbital coma 1. Lowers ICP and CMRO2 2. Decreases free radicals 3. Produces hypotension by decreasing sympathetic tone and causing myocardial depression 4. Increase dose until burst suppression achieved on electroencephalogram (EEG) 5. Insert Swan-Ganz catheter and nasogastric (NG) tube (for hyper-alimentation) 6. Dose—thiopental 5 mg/kg intravenously (IV) over 10 minutes, 5 mg/ kg/h × 24 hours, and 2.5 mg/kg/h to control ICP/EEG (level 6–8.5 mg/dL) 7. Consider propofol 10 μg/kg/min up to 170 μg/kg/min in place of barbiturates VII. OTHER MEASURES A. Fever control—cooling blanket and rectal Tylenol B. Carafate or Pepcid C. Deep vein thrombosis (DVT) prophylaxis—TED (thromboembolic deterrent) hose, sequential compression device (SCD), and heparin subcutaneously (SQ) D. Tube feeds after 3 days IX. SINUS WALL FRACTURE—treat with 10 days of antibiotic and surgical repair X. EPIDURAL HEMATOMA A. May watch if < 1 cm (be very careful) B. Use question mark or linear incision but be sure to expose low enough to reach foramen spinosum (middle meningeal artery) C. Consider placement of ICP monitor if there is also cerebral edema D. Have blood available XI. GUNSHOT WOUND A. Monitor ABCs (airway, breathing, circulation) and address other injuries B. Shave around the wound, irrigate and debride, and finally staple the wound closed C. Use anti-epileptic (e.g. keppra), Ancef, and tetanus toxoid D. Consider an angiogram to rule out vessel injury for lesions crossing the sylvian fissure or interhemispheric fissure E. Don’t operate if GCS 3–6 without a mass lesion XII. FACIAL PALSY—if partial or worsening, consider ENT (ear, nose, and throat) decompression; surgery rarely needed XIII. TENSION PNEUMOCEPHALUS—when nitrous oxide not stopped before dural closure; burr hole for subdural drain if symptomatic XV. BENIGN SUBDURAL COLLECTIONS OF INFANCY—most resolve spontaneously XVI. CEPHALOHEMATOMA A. Subgaleal hematoma—does not calcify, resolves spontaneously B. Subperiosteal hematoma 1. Occurs mainly in newborns and is limited by sutures 2. 80% resorb spontaneously. 3. May calcify 4. Surgical evacuation for cosmesis is performed after 6 weeks. XVII. CONCUSSION—transient altered mentation or loss of consciousness following head trauma A. For management guidelines for sports-related concussions, see Tables 7.1, 7.2, 7.3, and 7.4 XVIII. CSF LEAK—increased risk of infection, mainly from Streptococcus and Staphylococcus, and a mortality rate < 10% A. Rhinorrhea—CSF may travel from middle ear through eustachian tube to nasopharynx or directly through cribriform plate to nasopharynx B. Otorrhea—CSF leak requires perforated tympanic membrane C. Evaluation 1. CSF fluid glucose—should be > 30 (with tears and mucus it should be < 5) 2. B2-transferrin—found only in CSF
Cantu System | *AAN System* | |
1 (Mild) | A. PTA < 30 min | A. Transient confusion |
B. No LOC | B. No LOC | |
C. Symptoms resolve in < 15 min | ||
2 (Moderate) | A. LOC > 5 min, or B. PTA > 30 min | As above, but symptoms last > 15 min (still no LOC)(PTA is common) |
3 (Severe) | A. LOC ≥ 5 min, or B. PTA ≥ 24 h | Any LOC, whether brief (seconds) or prolonged |
Abbreviations: AAN, American Academy of Neurology; LOC, loss of consciousness; PTA, posttraumatic amnesia
A. | Persistent postconcussion symptoms |
B. | Permanent CNS sequelae from head injury (e.g., organic dementia, hemiplegia, homonymous hemianopsia) |
C. | Hydrocephalus |
D. | Spontaneous SAH from any cause |
E. | Symptomatic (neurologic or pain-producing) abnormalities about the foramen magnum (e.g., Chiari malformation) |
Abbreviations: CNS, central nervous system; SAH, subarachnoid hemorrhage
Concussion | Guidelines to Be Met before | |
No. | Severity | Return to Competition |
2 | Mild Moderate or severe | 1 Week* |
3 | Mild Moderate | Most consider this a season ending injury and recommend CT or MRI† Season-ending injury, consideration for ending all participation in contact sports |
2 | Severe | Season-ending injury, consideration for ending all participation in contact sports |
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging
*Without symptoms at rest and with exertion (see text)
Management Options* | |
1 (Mild) | A. Remove from contest B. Examine every 5 minutes for amnesia or postconcussive symptoms* C. May return to contest if symptoms clear within 15 min |
2 (Moderate) | A. Remove from contest B. Disallow return that day C. Examine on-site frequently for signs of evolving intracranial pathology D. Reexamination the next day by a trained individual E. CT or MRI if H/A or other symptoms worsen or last > 1 week† F. Return to practice after 1 full week without symptoms* |
3 (Severe) | A. Ambulance transport from field to ER if still unconscious or for concerning signs (C-spine precautions if indicated) B. Emergent neuro exam; neuroimaging as appropriate C. May go home with head-injury instructions if normal findings at time of initial neuro exam D. Admit to hospital for any signs of pathology or for continued abnormal mental status E. Assess neuro status daily until all symptoms have stabilized or resolved F. Prolonged unconsciousness, persistent mental status alterations, worsening postconcussion symptoms, or abnormalities on neuro exam → urgent neurosurgical evaluation or transfer to a trauma center G. After brief (< 1 min) grade 3 concussion, do not return to practice until asymptomatic for 1 full week* H. After prolonged (> 1 minute) grade 3 concussion, return to practice only after 2 full weeks without symptoms*‡ I. CT or MRI if H/A or other symptoms worsen or last > 1 week† |
Abbreviations: AAN, American Academy of Neurology; CT, computed tomography; ER, emergency room; H/A, headache; MRI, magnetic resonance imaging
*Evaluation at rest and with exertion (see text)
‡ Some experts also require a normal CT scan.
D. Treatment
1. Bed rest, stool softeners, acetazolamide (decreases CSF production), and fluid restriction (1500 mL/d)
2. Prophylactic antibiotics—not proven helpful
3. Leak persists > 3 days—place lumbar drain with head of bed (HOB) elevated 10 degrees and drip chamber at shoulder
a. Avoid tension pneumocephalus—treat by bedrest flat with 100% O2 and rarely aspiration
4. Leak persists > 2 weeks or patient develops meningitis—consider surgical intradural repair
Helpful Hints
- ABCs first
- Make sure spine is evaluated
- Rule out nonsurgical causes of depressed consciousness, e.g., illicit drugs, narcotics, hypoglycemia, hypoxia, hypotension, seizure
- Be aggressive with temporal (prepare for middle meningeal artery bleeding) and posterior fossa hematomas (prepare for sinus involvement).
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