Management of Moderate Head Injury

Aka: Management of Moderate Head Injury, Moderate Head Injury, Moderate Head Trauma, Moderate Traumatic Brain Injury, Moderate Closed Head Injury, Brain Injury Guidelines 2, BIG 2 Criteria in Traumatic Brain Injury

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II. Signs

  1. Glasgow Coma Scale: 9-12 (at two hours)
  2. Altered Level of Consciousness
    1. Prolonged loss of consciousness (>30 minutes)
    2. Confused or somnolent
    3. Follows simple commands
    4. Restlessness or Agitation
  3. Neurologic deficits
    1. Extremity weakness or numbness
    2. Slurred speech
    3. Coordination loss

III. Diagnosis: Brain Injury Guidelines 2 (BIG 2) Criteria

  1. Moderate Head Injury
    1. NO midline shift, mass effect or Herniation
    2. NO depressed Skull Fractures
      1. Non-displaced Skull Fractures are included in BIG 2
    3. If present, Hemorrhages meet moderate criteria
      1. NO intraventricular Hemorrhage
      2. Subdural Hematoma or Epidural Hematoma 5-7 mm thick
      3. Single intraparenchymal Hemorrhage 5-7 mm (or IPH in <=2 locations)
      4. Localized Subarachnoid Hemorrhage
  2. Intoxication may be present
  3. No Anticoagulation or antiplatelet use
  4. References
    1. Joseph (2014) J Trauma Acute Care Surg 76(4):965-9 +PMID: 24662858 [PubMed]
    2. Joseph (2022) J Trauma Acute Care Surg 93(2):157-65 +PMID: 35343931 [PubMed]

IV. Management

  1. See Management of Mild Head Injury
  2. See Management of Severe Head Injury
  3. Initial
    1. Same as in Management of Mild Head Injury
    2. CT Head in all cases
    3. Admit all for observation (or Transfer to Neurosurgery)
  4. Inpatient Monitoring
    1. Frequent neurologic checks
    2. Follow-up CT Head in 12-24 hours Indications
      1. Condition deteriorates or
      2. First CT abnormal or
      3. Per local protocol before discharge
  5. Disposition
    1. Patient improves (80-90%)
      1. Discharge after 48 hours
      2. Follow-up clinic
    2. Patient deteriorates (10-20%): Not following commands
      1. Repeat CT Head
      2. Follow Management of Severe Head Injury protocol

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