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Head Trauma, Blunt, Emergency Medicine


Basics


Description


Blunt trauma to head resulting in a variety of injuries ranging from closed head injury to death  

Etiology


Blunt trauma to head may cause several types of closed head injuries:  
  • Concussion: Transient (LOC) or amnesia with normal head CT
  • Subdural hematoma: Tearing of subdural bridging veins and bleeding into the subdural space
  • Epidural hematoma: Dural arterial injury, especially the middle meningeal artery often associated with a skull fracture:
    • Classically, transient LOC followed by a lucid interval, then rapid demise
  • Subarachnoid hemorrhage: Bleeding into the subarachnoid space following trauma
  • Cerebral contusion: Focal injuries to the brain characterized as coup (beneath area of impact) or contrecoup (area remote from impact)
  • Intracerebral hemorrhage: Mass intracranial lesion with bleeding into the brain parenchyma
  • Diffuse axonal injury: Microscopic injuries scattered throughout the brain in a patient in deep coma

Diagnosis


Signs and Symptoms


  • Evidence of trauma to head includes:
    • Scalp laceration, cephalohematoma, or ecchymosis
    • 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
    • Cerebral spinal fluid rhinorrhea or otorrhea
  • Evidence of increasing intracranial pressure includes:
    • Decreasing level of consciousness, falling score on Glasgow Coma Scale
    • Cushing response, bradycardia, HTN, and diminished respiratory rate
    • Dilated pupils associated with decorticate or decerebrate posturing

History
  • Mechanism
  • LOC or amnesia for event
  • Use of anticoagulants
  • Headache, visual changes, or hearing loss
  • Focal neurologic complaints
  • Associated neck pain

Physical Exam
  • Evaluation of head for hematoma, Battle sign, raccoon eyes
  • Complete neurologic exam
  • Exam of neck/cervical spine

Essential Workup


  • Imaging indicated for patients with any of the following:
    • LOC or amnesia of events
    • Progressive headache
    • Alcohol or drug intoxication
    • Unreliable history or dangerous mechanism
    • Post-traumatic seizure
    • Repeated vomiting
    • Signs of basilar skull fracture
    • Possible skull penetration or depressed skull fracture
    • Glasgow Coma Scale score <15
    • Focal neurologic findings
  • Patients on Coumadin, heparin, or other anticoagulants and those with a history of bleeding dyscrasias must undergo imaging.
    • If initial head CT is negative and <4 hr post injury, patient must be monitored and repeat head CT 4-6 hr post injury, or earlier if clinical deterioration.
  • Alcoholics have an increased risk for bleeding, low threshold for imaging

  • Older patients (>60-65 yr of age) are at higher risk of intracranial hemorrhage.
  • Many are on anticoagulation, take a careful hx.
  • Have a low threshold for obtaining CT scan.

Diagnosis Tests & Interpretation


Lab
  • Rapid check of blood glucose level
  • CBC, platelet count, and coagulation parameters
  • Type and cross-match for surgical candidates.
  • Baseline electrolytes, BUN, and creatinine levels
  • Blood alcohol level if indicated

Imaging
  • CT or MRI of head as indicated
  • Cervical spine radiographs or helical CT when indicated

Diagnostic Procedures/Surgery
Lumbar puncture if question of subarachnoid blood on head CT  

Differential Diagnosis


  • Penetrating head trauma
  • Any condition that alters mental status that may have produced a fall and caused external evidence of head trauma (e.g., hypoglycemic episode, seizure)

Treatment


Pre-Hospital


  • Blunt head trauma patients with risk for intracranial lesion must go to a trauma center:
    • High-risk patients include those with depressed consciousness, focal neurologic signs, multiple trauma, or palpable depressed skull fractures.
  • Moderate-risk patients should go to a hospital with availability of prompt neurosurgical consultation:
    • Moderate-risk patients include those with progressive headache, alcohol or drug intoxication, unreliable history, post-traumatic seizure, repeated vomiting, post-traumatic amnesia, signs of basilar skull fracture.
  • Protect and manage the airway, including intubation:
    • Routine hyperventilation without signs of cerebral herniation should be avoided.
  • If evidence of cerebral herniation (see Signs and Symptoms) or progressive neurologic deterioration in a normotensive patient, initiate measures to decrease intracranial pressure:
    • Mild hyperventilation to keep ETCO2 about 30-35 mm Hg:
      • 20 breaths/min in adults
      • 25 breaths/min in children
      • 30 breaths/min in infants <1 yr
    • Elevating head of bed 20-30 °
  • Cervical spine precautions must be maintained in all patients.
  • Cautions:
    • Avoid hypotension (systolic BP <90 mm Hg); use IV crystalloid solutions to maintain BP.
    • Avoid hypoxia (oxygen saturation <90%); administer 100% oxygen.
    • Check blood glucose level.

Initial Stabilization/Therapy


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 Pco2, 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

Ed Treatment/Procedures


  • 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 ETCO2 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

Medication


For RSI intubation, increased ICP, seizures, anticoagulation reversal, and pain control  
First Line
  • 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
  • Vecuroniumbromide: 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


Disposition


Admission Criteria
  • 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.

Discharge Criteria
  • 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.  
Issues for Referral
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.  

Followup Recommendations


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

Pearls and Pitfalls


  • 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.

Additional Reading


  • 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


ICD9


  • 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
  • 803.00 Other closed skull fracture without mention of intracranial injury, unspecified state of consciousness
  • 852.40 Extradural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness

ICD10


  • S06.0X0A Concussion without loss of consciousness, initial encounter
  • S06.5X0A Traum subdr hem w/o loss of consciousness, init
  • S09.90XA Unspecified injury of head, initial encounter
  • S02.91XA Unsp fracture of skull, init encntr for closed fracture
  • S06.4X0A Epidural hemorrhage w/o loss of consciousness, init encntr

SNOMED


  • 82271004 Injury of head (disorder)
  • 110030002 Concussion injury of brain (disorder)
  • 95453001 subdural intracranial hematoma (disorder)
  • 71642004 Fracture of skull (disorder)
  • 425359009 Blunt injury
  • 428268007 epidural hematoma (disorder)
  • 451000119106 Closed injury of head (disorder)
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