• A 38-year-old male presents to the ED after a motorcycle accident where he was flung from his seat and hit his head on a nearby pole. He was not wearing a helmet. Miraculously, paramedics found him early without any other injuries, albeit unconscious. He is on a backboard, bag-mask ventilated with an oropharyngeal airway and a C-spine collar as he enters the trauma bay. His blood pressure is 140/80 mmHg, pulse is 100/min, respirations are 22/min, and SaO2 of 95% on room air. Glasgow Coma Scale score is 3, with the left pupil that is 3 mm more dilated than his right. He is endotracheally intubated, sedated with propofol, the head of his bed is risen to 30°, and hyperventilated to 30 breaths/min while mannitol infusions are prepared. Immediate head CT reveals a left subdural hematoma with midline shift. ABG reveals pH 7.45, pCO2 32 mmHg. The patient is wheeled to the OR for emergent craniotomy.
  • Almost 2/3 of trauma admissions have head injuries
    • falls and motor vehicle collisions are leading mechanisms
  • Neurotrauma includes injuries to skull, facial, scalp, brain, and spinal cord
    • skull
      • basal skull fracture
        • hemotympanum, CSF rhinorrhea/otorrhea, Battle's sign , Raccoon eyes  
        • clinical diagnosis is best because of poor visualization on CT
      • vault fracture
        • non-depressed
          • typically over temporal bone (i.e., middle meningeal)
          • most common cause of epidural hematoma
        • depressed
          • either skin closed or open with lacerated dura 
    • facial
      • high risk of cranial nerve injury, infection, and airway compromise
    • scalp
      • lacerations can result in significant hemorrhage
    • brain
      • focal
        • contusion
          • most common brain lesion due to trauma
        • intracranial hemorrhage
          • can be due to coalescing of multiple contusions
          • includes epidural , subdural , intraparenchymal
      • diffuse
        • concussion/mild traumatic brain injury (TBI)
          • highest rates in children < 4y, teenagers, and elderly > 65y
        • diffuse axonal injury
    • spinal cord (SCI)
      • complete/incomplete transection
      • cord edema
      • spinal/neurogenic shock
      • whiplash-associated disorders
        • pericordal soft tissue injury around cervical spine due to extreme movement of neck
      • vertebral fracture
  • Clarify mechanism of injury and mental status before arrival to ED
    • transient altered mental status may include loss of consciousness (LOC)
      • consider TBI/concussion with following:
        • LOC < 30 minutes
        • post-trauma amnesia < 24 hours
        • initial GCS score between 13-15
      • if LOC/amnesia greater than indicated times, consider diffuse axonal injury
    • assume cord injury with significant falls > 10 feet, deceleration injuries, blunt trauma
      • normal neuro exam does not rule out SCI
      • SCI may be present even with normal C-spine radiograph
  • Vital signs
    • evidence of shock (hypotension/tachycardia despite fluid resuscitation)
    • evidence of increasing intracranial pressure
      • Cushing's triad: hypertension, bradycardia, irregular respirations
        • rare - if all three present, suggests poor prognosis
  • Physical exam
    • Glasgow Coma Scale score
      • changes in score more important than absolute score
        • change by > 3 points suggests severe injury
      • pupils
        • size, anisocoria, and response to light help prognose herniation injury
    • neurological exam
      • lateralizing cranial nerve and extremity motor/sensory deficits also guide severity of injury
  • Primary and seconary survey with resuscitation
  • Investigations
    • labs: CBC, electrolytes, BUN/Cr, glucose, PT/INR and PTT, toxicology screen
    • imaging: noncontrast CT and C-spine radiography (AP, lateral, odontoid)
      • lateral C-spine radiograph is most important
      • thoracolumbar/pelvic radiographs with AP and lateral views based on mechanism
      • MRI if soft tissue injury is suspected
  • Spinal immobilization (C-spine collar)
    • must be maintained until spinal injury has been ruled out by following criteria:
      • alert and oriented to person, place, time, and event (AOx4)
      • no evidence of intoxication
      • no posterior midline cervical tenderness
      • no focal neurological deficits
      • no other painful injuries
    • if any criterion abnormal but imaging is normal, consider flexion/extension rdaiography and/or MRI
      • if normal, C-spine is cleared
      • if abnormal, C-spine collar remains and neurosurgery/orthopedics consult
  • Acute neurotrauma
    • in addition to primary survey and resuscitation, emphasis on maintaining adequate cerebral perfusion pressure (CPP) in the emergent setting
      • remember, CPP = mean arterial pressure (MAP) - intracranial pressure (ICP)
      • hypoxia, hypercapnia, and ischemia can all lead to cerebral edema, and thus cause elevation in ICP → decrease in CPP
        • decreasing CPP can also result in seizures
    • medical management if evidence of increased ICP
      • raise head of bed to 30°
      • intubate with 100% O2
      • hyperventilate to pCO2 goal of 30-35 mmHg
      • sedate with propofol, morphine, vecuronium if anxious or agitated
      • mannitol bolus
      • seizure prophylaxis with levitiracetam (1st line) or phenytoin (2nd line)
    • early neurosurgical consult
  • Spinal cord injury
    • best next step: immobilize C-spine with collar and body with restraints
    • intubate with evidence of impending respiratory failure
    • treat neurogenic shock if present with fluid resucitation and vasopressors as needed
    • insert NG and Foley catheter
    • methylprednisolone only if SCI is isolated and nonpenetrating
      • otherwise not recommended
    • early neurosurgical/orthopedics consult for potential decompression
  • Mild TBI/concussion
    • admit if GCS score < 15, seizures, or severe bleeding present despite normal CT
    • admit if abnormal CT
    • observe and discharge with clear instructions
      • if cause is athletic, follow CDC 5-step Return to Play guidelines
  • Other considerations
    • Cushing's ulcer prophylaxis with H2 antagonists or proton pump inhibitor
    • DVT prophylaxis



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