Head Injury part 1

Head Injury
INITIAL EVALUATION AND TREATMENT OF HEAD INJURY

A. General:

1.Patients suspected of having suffered a head injury, particularly if confused or unresponsive, require emergency evaluation and treatment at a center with capabilities for immediate neurosurgical intervention. General objectives are rapid diagnosis and evacuation of intracranial mass lesions, expedient treatment of extracranial injuries, and avoidance of secondary brain injury due to hypoxia and hypotension. Other secondary insults such as hyperglycemia, hypothermia, and anemia may also exacerbate outcome during the hospital course.

2,Severe brain injury is associated with cerebral ischemia. Therefore, a principal therapeutic goal is to enhance cerebral perfusion and oxygenation and avoid further ischemic injury to the brain.

B. Initial management of the unresponsive patient with head injury:

1.Intubation with controlled ventilation (avoid routine hyperventilation). If possible, a focused neurologic examination, including assessment of GCS, pupillary response, and all four extremity movement, is critical before intubation and pharmacologic paralysis.

2.Venous access,,

* Restore intravascular volume, blood pressure, and perfusion.
*Avoid hypotonic or dextrose-containing solutions.

3.Immobilize the patient with rigid backboard and cervical spine (C-spine) collar. Assume that all patients with TBI have a spine injury until proved otherwise.

4.Pharmacologic paralysis and sedation, if agitated or combative,,

a.Short-acting agents are recommended.
*Vecuronium bromide, cisatracurium, or succinylcholine
*Opioid sedation: fentanyl or morphine
*Avoid benzodiazepines

5.Monitor blood pressure and O2 saturation continuously.

6.Check arterial blood gases (ABG), blood glucose, electrolytes, prothrombin time (PT), partial thromboplastin time (PTT), hematocrit, and platelet count. With active therapy, serum sodium levels and osmolality should be tracked.

7.Initiate medical management of the head injury. Proceed with rapid acquisition of a computed tomographic (CT) scan of the head and complete cervical spine (if time permits). Based on time, distance, and local capabilities, transfer may be necessary Rapid referral to a center capable of immediate neurosurgical intervention may be required. Do not delay transport to definitive care to obtain a CT scan of the head. Early diagnosis and evacuation of cranial mass lesions are critical.

8.Repeated neurologic examination and assessment of GCS. Documentation of the GCS in patients who are intubated, or “tubed,” should be noted by a T (i.e., 11[T]) patients who are intubated and pharmacologically paralyzed are noted by a TP (i.e., 3[TP]). This is needed for meaningful interpretation of the GCS values. # showing GCS #

9.Hyperventilation causes cerebral vasoconstriction and can worsen cerebral ischemia. Routine hyperventilation should no longer be used. Hyperventilation is indicated only in the setting of abrupt neurologic deterioration with suspected herniation.