Management of

Head Injury

American College of Surgeons

Committee on Trauma
April 1998
Management of Head Injury
I. Initial Management
A. Airway
Intubate* if:
1. Airway or ventilation is
inadequate
2. Patient remains unresponsive
(cannot protect airway)
3. Patient requires sedation for
diagnostic maneuvers
*If C-spine injury is suspected,
intubation should be performed
by the most experienced person
available. Use techniques that
cause the least movement of
head and neck.
B. Breathing
• Maintain Pco2 at normal levels
(>35 mmHg)
• Obtain chest X ray as soon as
possible
• Check ABGs or end tidal CO2
regularly
C. Circulation
• Shock is usually due to bleeding
from other sources
• Control bleeding
• Fluid resuscitate with isotonic
saline solutions as dictated by
other body injuries
• Shock will worsen the head injury
(keep systolic blood pressure
>90 mmHg)
C1 Cervical Spine
• Immobilize head and neck
• Obtain C-spine film as soon as
possible
This publication is designed to offer information suitable for use by an appropriately trained physician.
The information provided is not intended to be comprehensive or to offer a defined standard of care.
The user agrees to release and indemnify the American College of Surgeons from claims arising from
use of the publication.
by Thomas G. Saul, MD, FACS, in conjunction with the Joint Section
on Neurotrauma and Critical Care of the American Association of
Neurological Surgeons and Congress of Neurological Surgeons
II. Initial Neuro-Assessment Note Symmetry of Examine Pupils and Record
Motor Examination SIZE SHAPE* REACTION*
Key History • Do both arms move the same N o n e _________________
and equally strong?
• Mechanism of injury • Neuro-examination at scene Right _________ _________ B r i s k _________________
• Do both legs move the same and Sluggish _____________
• Response at scene • Changes in neuro-status
equally strong?
Asymmetrical motor responses N o n e _________________
should increase suspicion of an
Examination: Glasgow Coma Scale Left _________ _________ B r i s k _________________
intracranial mass lesion that
Best Verbal Response Sluggish _____________
Best Eye Opening requires immediate operation.
5 Converses, oriented * An oval pupil or sluggish reaction may indicate impending herniation.
4 Spontaneously
3 Voice 4 Converses, disoriented
3 Inappropriate words
III. Immediate IV. Recognize and V. Other Considerations
2 To pain
2 Incomprehensible sounds
Neurosurgical Treat Herniation A. Lateral C-spine X ray (C1–C7/T1).
1 Not at all
1 No verbalization
Management A. Look for: Spine fracture can be present in
Obtain CT scan of head if: 5%–20% of patients with severe
Best Motor Response • Sudden deterioration in level of head injury.
• Patient is comatose consciousness (if patient initially
responsive) B. Control bleeding.
• GCS£13
6 Obeys Follows motor commands C.Immobilize obvious extremity
• Lateralizing neuro-examination • Dilating pupil
fractures.
reveals • Deterioration of motor response
5 Localizes Clearly pushes painful (especially if on side opposite D. Remove from spine board, BUT
—unequal pupils log-roll until entire spine is cleared
stimuli away dilating pupil)
—focal weakness radiographically, especially if C-
• Patient with abnormal level of spine fracture is present. 5%–10%
4 Withdraws Only withdraws arm or leg B. Treatment of patients with one spine fracture
consciousness is to be sedated
(flexion-withdrawal) to painful stimuli
for diagnostics or treatment • Contact neurosurgeon may have another spine fracture.
• Hyperventilation (Pco2=25–30
3 Abnormal flexion Flexion of arms with mmHg) VI. Pitfalls
Obtain neurosurgical consultation if:
(decorticate) extension of legs to stimuli
• Mannitol, 1 g/kg IV push (if BP
• Patient is comatose 1. Assume a spine injury until it is
stable and after neurosurgical ruled out.
• GCS£13 consultation)
2 Abnormal extension Extension of all extremities
• Lateralizing neuro-examination 2. Use an orogastric tube, not a
(decerebrate) to painful stimuli • Immediate CT scan or take to nasogastric tube, if an anterior
reveals
operating room for intracranial basilar skull fracture or midface
—unequal pupils operation (as directed by fracture is suspected.
1 Flaccid No response to painful
—focal weakness neurosurgeon)
stimuli 3. Hyperextension injury of head and
• CT scan is abnormal neck or direct trauma to neck can
cause a carotid artery injury.
Glasgow Coma Scale Total = 3–15
4. Systolic blood pressure <90 mmHg
can lead to secondary brain injury.
5. Never attribute neurologic
abnormalities solely to the
presence of drugs or alcohol.
©1998 American College of Surgeons