Management for Head Injury
Assessment : 3 important parameters: ABCs, GCS, pupil size
| Minor head injury (GCS >13) | Indications for admission: 1. Persistent headache and/or vomiting 2. CSF leak 3. Neurological deficit 4. Skull fracture 5. History of loss of consciousness 6. Amnesia – In ward: NBM, IV drip (no dextrose saline!), no sedation, monitor GCS – If pt deteriorates -> CT scan Exclude metabolic causes (e.g. hypoglycaemia) Do septic workup (exclude sepsis) |
| Moderate head injury (GCS 8 – 13) | All will be CT-scanned at ED NES will operate if any indication to do so In ward: as per mild head injury |
| Severe head injury (GCS 7 – 3) | Must scan to look for reversible causes of raised ICP but stabilise patient first Screen for other life-threatening injuries (likely to be multi-trauma patient) Management of ICP – to maintain CPP and prevent cerebral edema 1. Medical – osmosis diuresis, loop diuretics NOT steroids 2. Surgical – CSF diversion, decompression, removal of mass effect 3. Raise head of bed (improves venous drainage but could reduce BP to the head) 4. Intubate and hyperventilate (the induced constriction of blood vessels limits blood flow to the brain at a time when the brain may already be ischemic — hence it is no longer widely used. Furthermore, the brain adjusts to the new level of carbon dioxide after 48 to 72 hours of hyperventilation, which could cause the vessels to rapidly dilate if carbon-dioxide levels were returned to normal too quickly) 5. IV mannitol: create a hypertonic solution within the blood to draw water out of the neurons. This helps to reduce the fluid within intracranial space, however prolonged administration may lead to increase in ICP (must catheterise patient also; do not give if patient is unstable) Achieve haemodynamic stability – Check for long bone fractures – FAST for bleeding into abdominal cavity – ABG to detect acidosis – Keep monitoring patient and re-investigate where appropriate Operate if reversible cause found – Craniectomy (i.e. bone flap not replaced) or craniotomy (bone flap replaced after blood evacuated) [Burr hole usually not big enough to drain an acute bleed] – Evacuate clot – Insert endo-ventricular drain (EVD) if there is hydrocephalus Total sedation after operation, ward in ICU – Prevents patient from struggling which will raise ICP |
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