Rosen & Barkin's 5-Minute Emergency Medicine Consult (315 page)

Management of ABCs:

• Control airway as needed:
  
  • Rapid sequence intubation if Glasgow Coma Scale score <8, unable to protect airway, or evidence of hypoxia
    
  • Normalize Pco
    ₂
    , avoid hyperventilation and hypoventilation.
    
• Treatment with etomidate or fentanyl as induction agent, succinylcholine (pretreat with minidose paralytic), rocuronium, or vecuronium; morphine for ongoing sedation
  
• Caution with fentanyl in hemodynamically labile patients
  
• IV catheter placement with crystalloid solution as needed to avoid hypotension (keep systolic BP >90 mm Hg)
  
• Cervical spine precautions
  

• Early neurosurgical consultation
  
• If patient has evidence of cerebral herniation (see Signs and Symptoms), initiate measures to decrease intracranial pressure:
  
  • Mild
    hyperventilation: 20 breaths/min in adults, 25 breaths/min in children, and 30 breaths/min in infants <1 yr to keep ETCO
    ₂
    about 30–35.
    
  • Elevate head of bed 20–30°
    
  • Mannitol boluses IV: Do not administer mannitol unless systolic BP >100 mm Hg and patient is adequately fluid resuscitated
    
• Phenytoin to prevent
  early
  post-traumatic seizures
  
• Reverse hypocoagulable states
  
• The use of glucocorticoids is
  not
  recommended to lower intracranial pressure in head trauma patients.
  
• Barbiturates are
  not
  recommended in the initial ED treatment of head-injured patients.
  
• If definitive neurosurgical care is not immediately available, a single burr hole may preserve life until neurosurgical intervention can be obtained:
  
  • Perform only in comatose patients with decerebrate or decorticate posturing on the side of a known mass lesion who have not responded to hyperventilation and mannitol.
    
• Transfuse as needed to keep hematocrit >30%.
  
• Avoid hypothermia, which will increase risks of coagulopathy during surgery.
  
• Maintain NPO status.
  
• Surgery:
  
  • Surgical procedure based on findings of CT scan and neurosurgical consultation
    

For RSI intubation, increased ICP, seizures, anticoagulation reversal, and pain control

• Etomidate: 0.2–0.3 mg/kg IV
  
• Fentanyl: 3–5 μg/kg V if systolic BP >100 mm Hg
  
• Mannitol: 0.25–1 g/kg IV bolus
  
• Morphine sulfate: 2–20 mg IV (peds: 0.1 mg/kg IV up to adult doses)
  
• Phenytoin: 15–20 mg/kg IV up to 1,000 mg
  
• Rocuronium: 0.6 mg/kg IV
  
• Succinylcholine: 1–2 mg/kg IV
  
• Vecuronium bromide: 0.1 mg/kg IV; minidose pretreatment: 0.01 mg/kg IV
  
• Vitamin K:
  
  • To be used in patients on Coumadin with intracranial hemorrhage
    
  • 10 mg in 50 mL NS infused over 30 min
    
• Protamine sulfate:
  
  • To be considered if taking low molecular weight heparin (LMWH) with intracranial hemorrhage
    
  • If LMWH used <8 hr prior, use 1 mg protamine for each mg of LMWH slow IV push over 1–3 min
    
  • If LMWH used >8 hr prior, use 0.5 mg protamine for each mg of LMWH slow IV push over 1–3 min
    

FOLLOW-UP

• Patients with mass lesion associated with head trauma must be admitted to the ICU or undergo surgery.
  
• Patients with subarachnoid hemorrhage and diffuse axonal injury should be initially admitted to the ICU.
  
• Patients with ongoing symptoms including repetitive questioning, anterograde amnesia, or disorientation should be admitted to a monitored unit for neurologic evaluation.
  

• Patients with resolved symptoms, negative findings on head CT, and no other comorbid factors (e.g., intoxication, additional trauma needing treatment) may be discharged.
  
• Patients on anticoagulation need to be observed and have negative findings on a head CT at 4–6 hr after the injury prior to discharge.
  
• Patients with minor head trauma, no LOC or amnesia, and normal neurologic exam findings may be discharged home with a friend or family member and head injury instructions.
  

Cases of suspected nonaccidental trauma must be reported to the appropriate legal agency.

If there are symptoms of concussion, patient will need follow-up with PMD, sports medicine physician, or neurologist to determine whether return to sports will be safe.

Return if worsening headache, visual changes, confusion, focal neurologic changes, or other changes in clinical status.

• Failure to query about anticoagulant use and image appropriately
  
• Failure to aggressively reverse hypocoagulable states
  
• Failure to counsel patient with a concussion for no contact sports until cleared by PMD, sports medicine physician, or neurologist.
  

• Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury 2nd edition.
  Prehosp Emerg Care
  . 2008;12(suppl 1):S1–S52.
  
• Bernhardt DT. Concussion: emedicine:
  http://emedicine.medscape.com/article/92095-overview
  
• Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. XV. Steroids.
  J Neurotrauma.
  2007;24(suppl 1):S91–S95.
  
• Committee on Trauma.
  Head Trauma: Advanced Trauma Life Support
  . 8th ed. Chicago, IL: American College of Surgeons, 2008.
  
• Espinosa-Aguilar A, Reyes-Morales H, Huerta-Posada CE, et al. Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury.
  J Trauma
  . 2008;64(5):1327–1341.
  
• Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents—second edition.
  Pediatr Crit Care Med.
  2012;13(suppl 1):S1–S82.
  
• Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
  Chest.
  2012;141(suppl 2):e737S–e801S.
  
• Warner KJ, Cuschieri J, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury.
  J Trauma
  . 2007;62(6):1330–1336.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Head Trauma, Penetrating
  
• Spine Injury: Cervical, Adult
  

CODES

• 850.9 Concussion, unspecified
  
• 852.20 Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness
  
• 959.01 Head injury, unspecified
  

BASICS

Penetrating injury to intracranial contents:

• High-velocity penetration: Usually bullets, which cause trauma directly to brain tissue and also have a “shock wave” injury to local surrounding brain
  
• Low-velocity penetration: Usually knives, picks, or other sharp objects, with direct local trauma to brain tissue
  

• Direct penetration of the skull into the intracranial cavity by foreign object:
  
  • Direct or local damage to brain tissue
    
  • Intracranial hemorrhage, including subdural, epidural, and intraparenchymal bleeds
    
• A bullet that hits the skull, ricochets off, and does not fracture the skull can still cause significant trauma to the underlying brain tissue.
  

DIAGNOSIS

• Alteration in level of consciousness and neurologic exam varies based on object and location.
  
• Evidence of increasing intracranial pressure:
  
  • Decreasing level of consciousness
    
  • Falling Glasgow Coma Scale score
    
  • Cushing response: Bradycardia, hypertension, and diminished respiratory rate
    
  • Blown pupil associated with decorticate or decerebrate posturing
    
• Evidence of penetrating injury to head or basilar skull fracture, or object still remaining in head:
  
  • Raccoon eyes: Bilateral ecchymosis of orbits associated with basilar skull fractures
    
  • Battle sign: Ecchymosis behind the ear at mastoid process associated with basilar skull fracture
    
  • Hemotympanum
    
  • CSF rhinorrhea or otorrhea