In severe head trauma, control of airway and intravenous line placement are first priorities. One should assume that the patient has a fractured cervical spine and avoid turning the head; obtain cervical spine films in addition to skull films. Search for accompanying traumatic injury to abdominal and thoracic organs. If a patient has head injury and shock, assume that they are unrelated. Most patients are cared for in major trauma centers that use protocols for initial evaluation and resuscitation. Systematic approaches to trauma management help to avoid overlooking injuries that may not be initially apparent.

In obtaining the patient’s history, establish the mode of injury and whether there was an associated anoxic period. Were there other factors such as drug and alcohol ingestion, exposure and hypothermia, or other medical problems? Patients who “talk and then deteriorate” are at high risk of harboring an intracranial hematoma and may require immediate neurosurgical intervention.

All patients with head trauma require neurologic examination, which must include (i) careful documentation of the patient’s level of consciousness and ability to carry out mental tasks, (ii) a careful look at the tympanic membranes for evidence of basilar skull fracture (blood or cerebrospinal fluid), (iii) scalp examination for evidence of localized areas of trauma,
(iv) precise recording of pupillary size and reaction, and (v) a check for hemiparesis and presence or absence of upgoing toes. The Glasgow Coma Scale, a simple and reproducible scale that allows comparison of the patient’s state at different times, also should be done as part of the examination (Table 32.1).

Concussion is defined as an immediate and transient loss of consciousness or other neurological function after head injury. There may be amnesia for events before (retrograde) or after (anterograde) the amnesia.

Observation in the hospital for 24 to 48 hours and neurosurgical consultation are appropriate for a patient with any focal abnormalities on neurological examination, unconsciousness, abnormal mental status, skull fracture, intracranial abnormalities on computed tomography (CT), or head trauma that is thought to be significant despite a normal examination. The decision to hospitalize or send a patient home who has not been unconscious and who has a normal neurologic examination may be made after careful consideration of the severity of trauma and of who will look after and monitor the patient at home.

Patients who return to an emergency room within 48 hours of transfer to the community with any persistent complaint
relating to the initial head injury should be seen by or discussed with a senior clinician experienced in head injuries, and considered for a CT scan (grade B recommendation).

One of the most feared complications of head injury is the development of an acute subdural or epidural hematoma, which then may cause herniation (see Chapter 31) and fatal brainstem compression. Clinically, this process manifests itself as headache; decreased level of consciousness; and, late in the course, a dilated pupil that is usually on the side of the hematoma, secondary to pressure on the third nerve. Epidural hematoma most commonly represents arterial bleeding secondary to tearing the middle meningeal artery on the undersurface of the temporal bone. The patient may deteriorate after the trauma or experience a “lucid interval” only to deteriorate later. Most patients will have a fracture over the groove of the middle meningeal artery. Subdural hematoma is secondary to venous or arterial bleeding and also has the potential for brainstem compression. Subdural and epidural hematomas are diagnosed by CT scan or magnetic resonance imaging (MRI). Chronic subdural hematomas can present days or weeks after trauma, often in the elderly, and may cause slow behavioral changes, gait disturbances, headache, and incontinence.