Snapshot 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. Introduction 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 Presentation 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 Evaluation 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 Management 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