Head Injury

Table of Contents

Aliases

None noted

Patient Care Goals

  1. Limit disability and mortality from head injury by:
    1. Promoting adequate oxygenation
    2. Promoting adequate cerebral perfusion
    3. Limiting development of increased intracranial pressure
    4. Limiting secondary brain injury

Patient Presentation

Inclusion Criteria

Adult or pediatric patient with blunt or penetrating head injury – LOC or amnesia not required

Exclusion Criteria

No recommendations

Patient Management

Assessment

  1. Maintain cervical stabilization [see Spinal Care guideline]
  2. Primary survey per the General Trauma Management guideline
  3. Monitoring:
    1. Continuous pulse oximetry
    2. Frequent systolic and diastolic blood pressure measurement
    3. Initial neurologic status assessment [see Appendix VII – Neurologic Status Assessment] and reassessment with any change in mentation
    4. Moderate/severe head injury – apply continuous waveform ETCO2, if available
  4. Secondary survey pertinent to isolated head injury:
    1. Head – Gently palpate skull to evaluate for depressed or open skull fracture
    2. Eyes:
  5. Evaluate pupil size and reaction to light to establish baseline
  6. Reassess pupils if decrease in mentation
    1. Nose/mouth/ears – evaluate for blood/fluid drainage
    2. Face – evaluate for bony stability
    3. Neck – palpate for cervical spine tenderness or deformity
    4. Neurologic:
      1. Perform neurologic status assessment (GCS or AVPU)
      2. Evaluate for focal neurologic deficit: motor and sensory

Treatment and Interventions

NOTE: These are not necessarily the order they are to be done, but are grouped by conceptual areas

  1. Airway:
    1. Administer oxygen as appropriate with a target of achieving 94-98% saturation
    2. If patient unable to maintain airway, consider oral airway (nasal airway should not be used with significant facial injury or possible basilar skull fracture)
    3. Advanced airways can be used if BVM ventilation ineffective in maintaining oxygenation or if airway is continually compromised
    4. Nasal intubation should not be used in patients with head injury
  2. Breathing:
    1. For patients with a moderate or/severe head injury who are unable to maintain their airway: use continuous waveform capnography, and EtCO2 measurement if available, with a target EtCO2 of 35-40 mmHg
    2. Extraglottic airway placement or/endotracheal intubation should only be performed if BVM ventilation is inadequate to maintain adequate oxygenation with a target EtCO2 of 35-40 mmHg
    3. For patients with a severe head injury with signs of herniation: hyperventilate to a target EtCO2 of 30-35 mmHg as a short-term option, and only for severe head injury with signs of herniation
  3. Circulation:
    1. Wound care
      1. Control bleeding with direct pressure if no suspected open skull injury
      2. Moist sterile dressing to any potential open skull wound
      3. Cover an injured eye with moist saline dressing and place cup over it
    2. Moderate/severe closed head injury
      1. Blood pressure: avoid hypotension
        1. Adult (age greater than 10 yo): maintain SBP greater than or equal to 110 mmHg
        2. Pediatric: maintain SBP:
          1. less than 1 month: greater than 60 mmHg
          2. 1-12 months: greater than 70 mmHg
          3. 1-10 yo: greater than 70 + 2x age in years
    3. Closed head injury
      1. Consider administering NS fluid bolus to maintain blood pressure to above numbers and maintain cerebral perfusion
    4. Do not delay transport to initiate IV access
  4. Disability:
    1. Evaluate for other causes of altered mental status – check blood glucose
    2. Spinal assessment and management, per Spinal Care guideline
    3. Perform and trend neurologic status assessment (moderate/severe: GCS 3-13, P {pain} or U {unresponsive} on AVPU scale)
      1. Early signs of deterioration:
        1. Confusion
        2. Agitation
        3. Drowsiness
        4. Vomiting
        5. Severe headache
      2. Monitor for signs of herniation
    4. Severe head injury – Elevate head of bed 30 degrees
  5. Transport destination specific to head trauma
    1. Preferential transport to highest level of care within trauma system:
      1. GCS 3-13, P (pain) or U (unresponsive) on AVPU scale
      2. Penetrating head trauma
      3. Open or depressed skull fracture

Notes – Head Injury