Initial Assessment and Management of Head Injury

Hypotension (systolic blood pressure < 90 mm Hg) may increase mortality markedly after head injury. Lactated Ringer solution or normal saline are the resuscitation fluids of choice. Glucose solutions should be avoided because hyperglycemia may worsen the outcome. Hypertonic saline (HS) is being used increasingly. Effective resuscitation can be accomplished with as little as 1 to 2 mL/kg, and HS may have a variety of neuroprotective effects. If an adequate systolic blood pressure cannot be restored with 2 to 3 liters of crystalloid, packed RBCs should be given.

It is important to rigorously follow the Advanced Trauma Life Support guidelines. Up to 70% of severely head-injured patients will have thoracic, abdominal, or major orthopaedic injuries, which may require more immediate attention than the head injury. On occasion, a patient may be so hemodynamically unstable as to require urgent thoracotomy, laparotomy, or endovascular intervention before the head injury can be fully evaluated. Simultaneous ICP monitoring during the ongoing intervention should be considered.

It is important to obtain a computed tomography (CT) scan of the head as soon as possible during initial management so as to determine the degree and extent of structural damage to the brain and prepare for immediate operative intervention, if appropriate. When a large mass lesion or early evidence of significantly increased ICP (such as obliteration of the basal cisterns) is present, mannitol 0.5 to 1.0 mg/kg may be given to reduce ICP. However, mannitol may initiate a diuresis that causes or exacerbates hypotension.

Additional problems are posed by patients on anticoagulants or antiplatelet medications. If such a history cannot be elicited, an important component to the initial laboratory studies is determination of the international normalized ratio (INR) and clotting time. In patients with any evidence of traumatic intracranial bleeding, the INR must be corrected with vitamin K and fresh frozen plasma. Many are using recombinant factor VIIa for this purpose. Dealing with current antiplatelet agents is particularly problematic because platelet function may be impaired for up to 7 days. Platelet transfusions may be helpful. Desamino-D-arginine vasopressin (DDAVP) can be administered as well.

Unless a patient is on chronic steroid therapy, steroids are contraindicated as a treatment for head injury. Anticonvulsant prophylaxis should be initiated as soon as possible after severe head injury and maintained for 7 days unless the patient seizes. Dilantin and Keppra are the most frequently used drugs for this purpose.

At some early point, the spine must be evaluated because spinal injury occurs in more than 5% of severely head-injured patients. Cervical immobilization must be maintained with a collar until structural injury to the cervical spine is definitively excluded. It is important to remove a hard backboard as soon as possible, while maintaining the patient flat, to immobilize the thoracolumbar spine. Skin ischemia, potentially leading to decubiti, can begin after 30 minutes on a backboard, especially in hypotensive patients.

A plain radiograph of the spine, supplemented with CT scan, will rule out the majority of bony injuries, but the possibility remains of a significant ligamentous injury. Magnetic resonance imaging (MRI) within the first 24 to 48 hours of injury has been advocated as a reliable method of assessing for ligamentous damage, but many physicians prefer to leave a cervical collar in place until clinical assessment is complete.

Only gold members can continue reading. Log In or Register to continue