severe head injury
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Introduction
Glasgow coma scale (GCS) < 9.
Classification
- severe head injuries include:
Physical examination
- GCS
- pupil size, reactivity to light, symmetry (prior to administration of atropine, if given)
- motor & sensory exam, reflexes
- signs of increased intracranial pressure
- decerebrate posturing
- decorticate posturing
- dilated pupils - unilateral or bilateral
- asymmetric pupillary activity
- worsening neurologic status, unexplained by extracranial causes
Laboratory
- complete blood count (CBC)
- chem-7 (electrolytes, BUN, creatinine, glucose)
- type & screen
- prothrombin (PT) & partial thromboplastin (PTT) time
- urine toxicology
- blood alcohol level (BAL)
- arterial blood gas (ABG)
Procedure
ATLS protocol:
- intubate
- arterial blood gas
- maintain SBP > 100 mm Hg
- maintain spine precautions
Radiology
CT of head without contrast
Management
- surgical lesion
- to operating room for surgical therapy
- insertion of intracranial pressure (ICP) monitor
- contusions, edema, mass effect or abnormal basal cisterns
- ventriculostomy or ICP monitor
- correct bleeding diathesis, if present, prior to insertion
- Ancef 1.0 g IV for penetrating injury within 2 hours prior to insertion
- vancomycin 1.0 g IV if cephalosporin allergy
- fosphenytoin loading
- ventriculostomy or ICP monitor
- if no significant findings, prepare to ICP monitor
- arterial line
- central venous catheter for central venous pressure (CVP)
- if no signs of increased ICP:
- signs of increased ICP
- prophylactic anticonvulsants for at least 1 week
- loss of consciousness 12-24 hours
- intracranial hemorrhage
- depressed skull fracture
- brain contusion[2]