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] (or open in [QxMD Read])

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] (or open in [QxMD Read])
  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] (or open in [QxMD Read])
      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] (or open in [QxMD Read])

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] (or open in [QxMD Read])

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Ontology: Craniocerebral Trauma (C0018674)

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 262516006, 210042006, 213392001, 262517002, 82271004, 210015005, 157328009, 269339002, 281670009
English HEAD TRAUMA, Head Injuries, Injuries, Head, Injury, Head, Head injury NOS, Craniocerebral Injuries, Craniocerebral Injury, Head injury, NOS, Injuries to the head, Injuries, Craniocerebral, Injury of head, NOS, Injury, Craniocerebral, Unspecified injury of head, [X]Injuries to the head, INJ CRANIOCEREBRAL, HEAD INJ, CRANIOCEREBRAL INJ, INJ HEAD, head injury (diagnosis), head trauma, head injury, [X]Injuries to the head (disorder), Craniocerebral Trauma, Craniocerebral Traumas, Trauma, Craniocerebral, Traumas, Craniocerebral, Head Trauma, Head Traumas, Trauma, Head, Traumas, Head, Head injury NOS (disorder), INJURY, HEAD, HEAD INJURY, Craniocerebral Trauma [Disease/Finding], craniocerebral trauma, craniocerebral injury, head traumas, injuries to the head, Injury;head, head injuries, Head trauma, Injuries to the head (S00-S09), Craniocerebral injury, Head injury, HI - Head injury, Injury of head region, Injury of head (disorder), Injury of head, head; injury, injury; head, Injury of head region (disorder), 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, トヴガイノウソンショウ, 頭蓋脳損傷, 外傷-頭部, 頭部外傷
Czech hlava - poranění, kraniocerebrální poranění, kraniocerebrální trauma, Poranění hlavy, Kraniocerebrální poranění
Portuguese Traumatismos Craniocerebrais, Trauma Craniocerebral, Lesão Craniocerebral, Lesões Craniocerebrais, Lesões Cranioencefálicas, Lesão crânio-cerebral, Lesão traumática da cabeça, Lesões da Cabeça, Trauma Craniano, Traumatismo da Cabeça, Traumatismos da Cabeça
Spanish Head injury NOS, Injury of head region, Injury of head region [Ambiguous], Traumatismos Craneocerebrales, Trauma Craneocerebral, Lesion Craneocerebral, Lesión Craneocerebral, Lesiones Craneocerebrales, [X]lesiones en la cabeza (trastorno), [X]lesiones en la cabeza, Lesión craneocerebral, injuria de la cabeza, injuria de la región de la cabeza (trastorno), injuria de la región de la cabeza, lesión de la cabeza, SAI (trastorno), lesión de la cabeza, SAI, lesión traumática de la cabeza (trastorno), lesión traumática de la cabeza, traumatismo craneoencefálico (trastorno), traumatismo craneoencefálico, Traumatismo craneoencefálico, Lesiones Craneoencefalicas, Lesiones de la Cabeza, Trauma de la Cabeza, Traumatismos Craneoencefalicos, Traumatismos de la Cabeza, Lesiones Craneoencefálicas, Traumatismos Craneoencefálicos
Finnish Kallo-aivovammat
German Nicht naeher bezeichnete Verletzung des Kopfes, Kraniozerebrale Verletzung, Kopfverletzung, Kopfverletzungen, Schädelhirntrauma, Schädeltrauma
Korean 상세불명의 머리 손상
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
Dutch craniocerebraal letsel, hoofd; letsel, letsel; hoofd, Niet gespecificeerd letsel van hoofd, hoofdletsel, Craniocerebraal trauma, Hoofdletsel, Hoofdtrauma, Trauma, craniocerebraal, Trauma, craniocerebraal-
Hungarian Fejsérülés, Craniocerebralis sérülés

Ontology: Closed head injuries (C0085094)

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
English Closed Head Injuries, Closed Head Injury, Head Injuries, Closed, Head Injury, Closed, Injuries, Closed Head, Closed head injuries, Closed head injury, HEAD INJ NONPENETRATING, INJ CLOSED HEAD, CLOSED HEAD INJ, HEAD INJ CLOSED, HEAD INJURY 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, close head injury, closed head trauma, close head injuries, closed head injury, Injury;closed head
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
Italian Traumatismo chiuso del capo, Lesioni chiuse del capo
Portuguese Lesão traumática de cabeça fechada, Lesões Cranianas Fechadas, Lesões da Cabeça não Penetrantes, Traumatismos Cranianos Fechados, Traumatismos da Cabeça Fechados
Spanish Lesión cerrada en la cabeza, Lesiones Cerradas de la Cabeza, Trauma Cerrado de Cabeza, Traumatismos Cerrados de la Cabeza, Traumatismos de la Cabeza no Penetrantes
Japanese 閉鎖性頭部損傷, ヘイサセイトウブソンショウ, 頭部外傷-非開放性, 非開放性頭部外傷, 閉鎖性頭部外傷, 頭部外傷-閉鎖性
Swedish Huvudskador, slutna
Czech hlava - poranění bez otevřené rány, 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
Polish Urazy głowy zamknięte
Hungarian Zárt fejsérülés