Management of Severe Head Injury

1. See Also
   1. Head Injury
   2. Management of Mild Head Injury
   3. Management of Moderate Head Injury
2. Indications
   1. Glasgow Coma Scale (GCS) <= 8 (Coma)
3. Evaluation
   1. See Head Injury
   2. Primary Survey (ABCDE)
   3. Secondary survey
   4. AMPLE history
   5. Neurologic Exam
      1. Glasgow Coma Scale
      2. Pupillary light reaction
      3. Oculocephalic (Doll's Eyes): if no spinal injury
      4. Oculovestibular Testing
4. Labs
   1. Urine Drug Screen
   2. Blood Alcohol Level
5. Imaging
   1. Head CT
   2. C-Spine CT
   3. Other imaging as indicated as part of Trauma Evaluation
6. Management: Increased Intracranial Pressure
   1. Transfer to Neurosurgery
   2. See Increased Intracranial Pressure management
   3. Mannitol (20%)
      1. Dose: 1 g/kg bolus over 5 minutes
      2. Avoid if hypotensive
   4. Moderate Hyperventilation
      1. Keep pCO2 25-30 mmHg
      2. Avoid lowering pCO2 below 25
         1. Risk of cerebral ischemia
7. Management: Seizures
   1. Anticonvulsants as indicated
   2. Seizure Prophylaxis
      1. No benefit in children if no immediate Seizure
         1. Young (2004) Ann Emerg Med 43:435-46
      2. Agents
         1. Phenobarbital
         2. Phenytoin
   3. Acute Seizure control
      1. Diazepam
      2. Lorazepam
8. Precautions
   1. Do not lower Blood Pressure
   2. Avoid Systemic Corticosteroids (increases mortality)
      1. Roberts (2004) Lancet 364:1321-8
9. Diagnostics: Testing in Unknown Injury
   1. Head Evaluation
      1. CT Head in all patients
      2. Air ventriculogram
      3. Cerebral Angiogram
   2. Abdominal Evaluation
      1. If Systolic Blood Pressure <100 mmHg
         1. Diagnostic Peritoneal Lavage
         2. Abdominal Ultrasound
         3. Exploratory Laparotomy/Celiotomy as needed
      2. If Systolic Blood Pressure >100 mmHg
         1. Dilated, non-reactive pupils, unilateral weakness
            1. Immediate CT Head
            2. Diagnostic Peritoneal Lavage
            3. CT Abdomen
         2. No focal or pupil changes
            1. CT Abdomen at time of Head CT