II. Pathophysiology

  1. Intracranial Pressure (ICP) association with injury
    1. Note measurements are in mmHg, not cmH2O
    2. Normal: 10 mmHg ICP
    3. Abnormal: 20 mmHg ICP
    4. Severe: 40 mmHg ICP
    5. Herniation: 50 mmHg ICP
  2. Cushing's Response
    1. Hypertensive response in face of increased ICP
    2. Helps maintain cerebral perfusion
    3. Do not use antihypertensives to lower Blood Pressure
      1. Results in decreased brain perfusion
      2. Exception: Intracranial bleeding (e.g. aneurysmal bleeding)

III. Precautions: Respiratory status in Head Injury

  1. Target PaO2: 200-300 mmHg
    1. PaO2 <200 mmHg and PaO2 >300 mmHg are both associated with higher mortality
    2. Option 1: Wean FIO2 to 50%, but still maintain O2Sat at 99-100% or
    3. Option 2:
      1. Wean oxygen to point that O2Sat starts to drop below 99-100% and
      2. Then increase the delivered oxygen by 2-4 L/min above that level
  2. Avoid Hyperventilation following intubation
    1. Hyperventilation is associated with worse outcomes in traumatic brain injury
    2. Monitor End-Tidal CO2 or capnometer following intubation
    3. Maintain pCO2 at 35-40 mmHg
    4. Maintain Respiratory Rate at 10-12 breaths per minute
  3. References
    1. Majoewsky (2012) EM:RAP 12(5): 1-2
    2. Davis (2009) J Neurotrauma 26(12): 2217-23 [PubMed]

IV. Assessment

  1. Glasgow Coma Scale (GCS)
    1. First GCS at the initial emergency Trauma Evaluation is the best indicator of outcome at one year
    2. Goal in trauma is to optimize care and allow the best chance for recovery to the initial GCS
  2. Pupil exam
  3. Neurologic Exam
    1. Motor Exam
    2. Sensory Exam
    3. Reflex Exam
  4. Alcohol or drug intake history
  5. Vital Signs
    1. Hypertension is typical response (see Cushing's Response above)
    2. Hypotension seen in pediatric Closed Head Injury
      1. Patrick (2002) Am J Surg 184:555-60 [PubMed]
  6. Signs Skull Fracture
    1. See Skull Fracture
    2. Vault Skull Fracture
    3. Basilar Skull Fracture
      1. CSF Rhinorrhea or Otorrhea
      2. Hemotympanum
      3. Post-auricular Bruising (Battle's Sign)
      4. Orbital Bruising (Raccoon's Eyes)
      5. CN VII palsy (Bell's Palsy)
  7. Signs Intracranial Injury
    1. Focal
      1. Epidural Hemorrhage
      2. Subdural Hemorrhage
      3. Intracerebral Hemorrhage
    2. Diffuse
      1. Mild Concussion
      2. Classic Concussion
      3. Diffuse Axonal Injury
  8. Scalp Lacerations with Hemorrhage
    1. Risk of significant blood loss to the point of Hemorrhagic Shock (especially children)
    2. Apply direct pressure to prevent further bleeding
    3. Close bleeding scalp lesions quickly (even temporarily) with Sutures, staples or Raney Clips
    4. Carefully investigate Laceration for associated complications prior to final closure
      1. Skull Fracture (deformity, bony fragments, CSF leakage)
      2. Subgaleal Hemorrhage may appear similar to Skull Fracture with deformity at the floor of the Laceration

V. Imaging: CT Head Indications

  1. Head CT in all cases of moderate or Severe Head Injury
  2. Mild Head Injury Indications
    1. See Head Injury CT Indications in Adults
    2. See Head Injury CT Indications in Children
      1. Consider Head MRI in children in place of Head CT (due to radiation risk)
    3. Coagulopathy or oral Anticoagulant (e.g. Warfarin, Plavix)
      1. Approach based on evidence below
        1. Consider imaging all patients on Anticoagulants regardless of Head Injury severity
        2. Consider repeat CT Head imaging at 24 hours for patients on Warfarin regardless of signs or symptoms
        3. Consider 24 hour observation and repeat CT Head for elderly patients or those with INR >3
        4. Newman in Herbert (2014) EM:Rap 14(1): 6
      2. Even Minor Head Injury on oral Anticoagulants is associated with a significant risk of bleeding (and often without red flag findings)
        1. Clopidogrel was associated with an initial 12% CNS HemorrhageIncidence, but no delayed bleeding
        2. Warfarin was associated with an initial 6% CNS HemorrhageIncidence with 0.6% having delayed bleeding
        3. Nishijima (2012) Ann Emerg Med 59(6): 460-8 [PubMed]
      3. Warfarin is associated with delayed intracranial bleeding in 6% of patients at 24 hours (may be delayed as long as 1 week after Head Injury)
        1. Most of these patients with CNS Hemorrhage on Warfarin had GCS 14-15 and no focal neurologic changes
        2. Menditto (2012) Ann Emerg Med 59(6): 451-5 [PubMed]

VII. Evaluation: Age under 2 years

  1. See Head Injury CT Indications in Children
  2. Red Flags suggestive of serious injury
    1. Skull Fracture
    2. Scalp swelling (80-100% of Skull Fracture)
    3. Younger the age, the greater the risk
    4. Non-accidental trauma (Child Abuse)
    5. No clear history of trauma
  3. Symptoms that do not predict serious Head Injury
    1. Loss of consciousness
    2. Vomiting
  4. References
    1. Dachs (2012) AAFP Board Review Express, San Jose

VIII. Management

  1. See Management of Mild Head Injury (GCS 13-15 at two hours)
  2. See Management of Moderate Head Injury (GCS 9-12 at two hours)
  3. See Management of Severe Head Injury (GCS 3-8 at two hours)
  4. Avoid Systemic Corticosteroids (increases mortality)
    1. Roberts (2004) Lancet 364:1321-8 [PubMed]

Images: Related links to external sites (from Google)

Ontology: Craniocerebral Trauma (C0018674)

Definition (MSHCZE) Úrazová poškození kraniálních a intrakraniálních struktur hlavy (např. MOZEK, KRANIÁLNÍ NERVY, MENINGY a další struktury hlavy). Zranění mohou být klasifikována podle toho, zda proniknou lebkou či nikoli nebo zda jsou spojena s krvácením.
Definition (MEDLINEPLUS)

Chances are you've bumped your head before. Usually, the injury is minor because your skull is hard and it protects your brain. But other head injuries can be more severe, such as a skull fracture, concussion, or traumatic brain injury.

Head injuries can be open or closed. A closed injury does not break through the skull. With an open, or penetrating, injury, an object pierces the skull and enters brain tissue. Closed injuries are not always less severe than open injuries.

Some common causes of head injuries are falls, motor vehicle accidents, violence, and sports injuries.

It is important to know the warning signs of a moderate or severe head injury. Get help immediately if the injured person has

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • An inability to wake up
  • Dilation of one or both pupils of the eyes
  • Slurred speech
  • Weakness or numbness in the arms or legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation

NIH: National Institute of Neurological Disorders and Stroke

Definition (NCI) A traumatic injury to the head.
Definition (LNC) Head trauma, especially basal skull/temporal bone fracture that requires hospitalization.
Definition (MSH) Traumatic injuries involving the cranium and intracranial structures (i.e., BRAIN; CRANIAL NERVES; MENINGES; and other structures). Injuries may be classified by whether or not the skull is penetrated (i.e., penetrating vs. nonpenetrating) or whether there is an associated hemorrhage.
Concepts Injury or Poisoning (T037)
MSH D006259
ICD9 959.01
ICD10 S00-S09.9 , S09.9, S09.90, S00-S09
SnomedCT 213392001, 210042006, 269339002, 281670009, 262517002, 262516006, 210015005, 157328009, 82271004
LNC LA17540-8, LA12679-9
English Head Injuries, Injuries, Head, Injury, Head, Craniocerebral Injuries, Craniocerebral Injury, Injuries to the head, Injuries, Craniocerebral, Injury, Craniocerebral, Unspecified injury of head, [X]Injuries to the head, INJ CRANIOCEREBRAL, HEAD INJ, CRANIOCEREBRAL INJ, INJ HEAD, head injury (diagnosis), head injury, Craniocerebral Trauma, Craniocerebral Traumas, Trauma, Craniocerebral, Traumas, Craniocerebral, Head Trauma, Head Traumas, Trauma, Head, Traumas, Head, Head injury NOS, Craniocerebral Trauma [Disease/Finding], craniocerebral trauma, craniocerebral injury, head traumas, injuries to the head, Injury;head, head injuries, Injuries to the head (S00-S09), Craniocerebral injury, head trauma (diagnosis), head trauma, [X]Injuries to the head (disorder), Injury of head region (disorder), Head injury NOS (disorder), Head trauma, HEAD INJURY, Injury of Head, INJURY, HEAD, Injury-head, Head injury, HI - Head injury, Injury of head region, Injury of head (disorder), Injury of head, head; injury, injury; head, Head injury, NOS, Injury of head, NOS, Injury of head region [Ambiguous], Head Injury, Head injury, unspecified
Italian Traumatismo al capo, Lesioni craniocerebrali, Lesioni del capo, Trauma del capo, Lesione craniocerebrale, Trauma craniocerebrale
Swedish Kraniocerebralt trauma
Japanese トウブソンショウ, 頭部損傷, 側頭部外傷, 頭損傷, 頭頂部外傷, 前頭部外傷, 後頭部外傷, 外傷-頭部, 頭部外傷, 頭蓋脳損傷, トヴガイノウソンショウ
Czech hlava - poranění, kraniocerebrální poranění, kraniocerebrální trauma, Poranění hlavy, Kraniocerebrální poranění
Portuguese Traumatismos Craniocerebrais, Lesão crânio-cerebral, Lesões da Cabeça, Lesão Craniocerebral, Trauma Craniano, Lesões Cranioencefálicas, Trauma Craniocerebral, Lesões Craniocerebrais, Traumatismos Cranioencefálicos, Lesão traumática da cabeça, Traumatismo da Cabeça, Traumatismos da Cabeça
Spanish Traumatismos Craneocerebrales, Lesión craneocerebral, lesión de la cabeza, SAI, [X]lesiones en la cabeza (trastorno), lesión de la cabeza, SAI (trastorno), injuria de la región de la cabeza, injuria de la región de la cabeza (trastorno), [X]lesiones en la cabeza, Lesión Craneocerebral, Lesiones Craneoencefálicas, Trauma Craneocerebral, Lesiones Craneocerebrales, Lesiones de la Cabeza, Traumatismos Craneoencefálicos, injuria de la cabeza, lesión traumática de la cabeza (trastorno), lesión traumática de la cabeza, traumatismo craneoencefálico (trastorno), traumatismo craneoencefálico, Traumatismo craneoencefálico, Trauma de la Cabeza, Traumatismos de la Cabeza
Finnish Kallo-aivovammat
Russian ZATYLOCHNOI OBLASTI TRAVMY, LOBNOI OBLASTI TRAVMY, GOLOVY TRAVMY, TEMENNOI OBLASTI TRAVMY, VISOCHNOI OBLASTI TRAVMY, CHEREPNO-MOZGOVYE TRAVMY, ВИСОЧНОЙ ОБЛАСТИ ТРАВМЫ, ГОЛОВЫ ТРАВМЫ, ЗАТЫЛОЧНОЙ ОБЛАСТИ ТРАВМЫ, ЛОБНОЙ ОБЛАСТИ ТРАВМЫ, ТЕМЕННОЙ ОБЛАСТИ ТРАВМЫ, ЧЕРЕПНО-МОЗГОВЫЕ ТРАВМЫ
German Nicht naeher bezeichnete Verletzung des Kopfes, Kraniozerebrale Verletzung, Kopfverletzung, Kopfverletzungen, Schädelhirntrauma, Schädeltrauma
Korean 상세불명의 머리 손상
Croatian KRANIOCEREBRALNE OZLJEDE
French TCE (Traumatisme CranioEncéphalique), Traumatismes cranioencéphaliques, TCC (Traumatisme CranioCérébral), Traumatismes craniocérébraux, Lésion cranio-cérébrale, Lésion de la tête, Traumatisme crânien, Traumatisme cranio-cérébral, Traumatismes cranio-cérébraux, Traumatisme craniocérébral, Lésions traumatiques de la tête, Traumatismes cranio-encéphaliques, Traumatismes crâniens, Traumatismes de la tête
Polish Urazy czaszkowo-mózgowe, Uraz czaszki zmiażdżeniowy
Hungarian Fejsérülés, Craniocerebralis sérülés
Dutch craniocerebraal letsel, hoofd; letsel, letsel; hoofd, Niet gespecificeerd letsel van hoofd, hoofdletsel, Craniocerebraal trauma, Hoofdletsel, Hoofdtrauma, Trauma, craniocerebraal, Trauma, craniocerebraal-
Norwegian Hodeskader, Kranieskader, Traume mot hodet, Traume mot skallen, Traume mot kraniet

Ontology: Closed head injuries (C0085094)

Definition (MSHCZE) Poranění lebky v situaci, kdy není narušena lebka jiným objektem či úlomkem kosti, který by pronikl skrz dura mater. Obvykle je to výsledkem mechanického poškození přeneseného na intrakraniální struktury hlavy, v nichž může dojít k poškození mozku, ke krvácení nebo k poranění kraniálních/hlavových nervů. (In: Rowland, Merritt's Textbook of Neurology, 9.vyd., s. 417)
Definition (MSH) Traumatic injuries to the cranium where the integrity of the skull is not compromised and no bone fragments or other objects penetrate the skull and dura mater. This frequently results in mechanical injury being transmitted to intracranial structures which may produce traumatic brain injuries, hemorrhage, or cranial nerve injury. (From Rowland, Merritt's Textbook of Neurology, 9th ed, p417)
Concepts Injury or Poisoning (T037)
MSH D016489
SnomedCT 451000119106
English Closed Head Injuries, Closed Head Injury, Head Injuries, Closed, Head Injury, Closed, Injuries, Closed Head, Closed head injuries, HEAD INJ NONPENETRATING, INJ CLOSED HEAD, CLOSED HEAD INJ, HEAD INJ CLOSED, Closed Head Trauma, Closed Head Traumas, Head Trauma, Closed, Head Traumas, Closed, Trauma, Closed Head, Traumas, Closed Head, Head Injuries, Nonpenetrating, Head Injury, Nonpenetrating, Nonpenetrating Head Injuries, Nonpenetrating Head Injury, Head Injuries, Closed [Disease/Finding], closed head injuries, closed head injury, close head injury, closed head trauma, close head injuries, Closed injury of head, Closed head injury, Closed injury of head (disorder), Injury;closed head
Swedish Huvudskador, slutna
Czech hlava - poranění bez otevřené rány, Uzavřené poranění hlavy, uzavřené poranění hlavy
Finnish Suljetut kallovammat
French Traumatismes fermés de la boite crânienne, Traumatisme crânien fermé, Traumatismes crâniens fermés, Traumatismes crâniens non pénétrants, Traumatismes fermés de la boîte crânienne
Russian GOLOVY TRAVMY ZAKRYTYE, ГОЛОВЫ ТРАВМЫ ЗАКРЫТЫЕ
Japanese 頭部外傷-非開放性, 閉鎖性頭部損傷, ヘイサセイトウブソンショウ, 非開放性頭部外傷, 閉鎖性頭部外傷, 頭部外傷-閉鎖性
Croatian GLAVA, OZLJEDE, ZATVORENE
Polish Urazy głowy zamknięte
Spanish Lesión cerrada en la cabeza, lesión traumática cerrada de la cabeza (trastorno), lesión traumática cerrada de la cabeza, Lesiones Cerradas de la Cabeza, Trauma Cerrado de Cabeza, Traumatismos Cerrados de la Cabeza, Traumatismos de la Cabeza no Penetrantes
Portuguese Lesão traumática de cabeça fechada, Lesões Cranianas Fechadas, Lesões da Cabeça não Penetrantes, Traumatismos Cranianos Fechados, Traumatismos da Cabeça Fechados
Dutch gesloten hoofdletsel, Gesloten hoofdletsel, Gesloten hoofdletsels, Hoofdletsel, niet-penetrerend, Hoofdletsels, gesloten, Hoofdtrauma, gesloten, Letsel, gesloten hoofd-, Letsels, gesloten hoofd-
German Geschlossene Kopfverletzung, Kopfverletzungen, geschlossene, Kopftrauma, geschlossenes, Kopfverletzungen, nicht penetrierende, Gedecktes Schädelhirntrauma, Geschlossenes Schädelhirntrauma, Schädelhirntrauma, gedecktes, Schädelhirntrauma, geschlossenes
Hungarian Zárt fejsérülés
Italian Traumatismo chiuso del capo, Lesioni chiuse del capo
Norwegian Ikke-penetrerende hodeskader, Hodeskader uten gjennomtrengende sår, Lukkede hodeskader