Head trauma (main): Difference between revisions

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{{AdultPage|head trauma (peds)}}
==Background==
==Background==
*Main goals in management:
[[File:TBI GCS.jpg|thumb|TBI epidemiology by GCS.]]
**Prevent intracranial hypertension
*Also known as Traumatic Brain Injury (TBI): Impairment in brain function from a mechanical force
**Prevent secondary brain insults
{{TBI pathophysiology}}
**Maintain CPP > 70 mmHg
**Optimize cerebral oxygenation and blood flow
*Severe TBI defined as head trauma and GCS 3-8<ref>Teasdale G, Jennett B: Assessment of coma and impaired consciousness: A practical scale. Lancet. 1974, 2: 81-84.</ref>
[[File:TBI GCS.jpg|thumb]]


==Clinical Features==
==Clinical Features==
{{GCS table}}
*Adult patient with blunt head trauma


==Differential Diagnosis==
==Differential Diagnosis==
{{Intracranial hemorrhage DDX}}
{{Head trauma DDX}}
{{Blunt neck trauma DDX}}


{{Maxillofacial trauma DDX}}
==Evaluation==
{{GCS table}}


{{Blunt neck trauma DDX}}
===Workup===
''Workup is dependent on [[GCS]] severity, see:''
*[[Mild traumatic brain injury]] ([[GCS]] 14-15)
**[[Clinical decision rules for head CT in trauma]]
*[[Moderate-to-severe traumatic brain injury]]  ([[GCS]] <14)


===Other===
==Management & Disposition==
*[[Concussion]]
''Dependent on underlying diagnosis, see:''
*[[Severe traumatic brain injury]]
*[[Traumatic intracerebral hemorrhage]]
 
*[[Moderate-to-severe traumatic brain injury]]
==Evaluation==
**[[Elevated intracranial pressure]]
{{Head trauma workup}}
*[[Mild traumatic brain injury]]
*Labs
*[[Post-concussive syndrome]]
**Immediate blood glucose level
**Serial ABGs with focus on PaO2, PaCO2, acid-base status
**Hb assessment with consideration for transfusion with Hb < 7 mg/dL
**PT/INR/PTT
**Electrolytes
***Hyponatremia, hypomagnesemia, hypophosphatemia lower seizure threshold
===Monitoring===
*Core temperature, Foley with bladder probe
*ICP monitoring
*Jugular venous oxygen saturation (SjvO2) by retrograde catherization of right IVJ associated with improved outcomes<ref>Cruz J: The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management strategies and clinical outcome. Crit Care Med. 1998, 26: 344-351.</ref>
**Normal range 55-70%
**Sustained desaturation < 50% requires aggressive treatment<ref>Robertson CS, Cormio M: Cerebral metabolic management. New Horiz. 1995, 3: 410-422.</ref>
*Transcranial doppler around thinner walls of skull (insonation windows)<ref>de Freitas GR, Andre C: Sensitivity of transcranial Doppler for confirming brain death: A prospective study of 270 cases. Acta Neurol Scand. 2006, 113: 426-432.</ref><ref>Dosemeci L, Dora B, Yilmaz M, et al: Utility of transcranial Doppler ultrasonography for confirmatory diagnosis of brain death: Two sides of the coin. Transplantation. 2004, 77: 71-75.</ref>
**Temporal region above zygomatic arch, through eyes, below jaw, behind occiput
**Sensitivity for brain death is ~75%, specificity 98%


==Management==
== Calculators ==
*Monitor for increased ICP
{{GCS_Calculator}}
*Monitor for herniation
*Maintain PaO2>60
*Prevent hyperthermia
*Prevent hypotension


{{Increased ICP treatment}}
{{Canadian_CT_Head_Calculator}}


==See Also==
==See Also==
*[[Pediatric head trauma]]
*[[Pediatric head trauma]]
*[[Coup contrecoup injury]]


==References==
==References==

Latest revision as of 15:05, 21 March 2026

This page is for adult patients. For pediatric patients, see: head trauma (peds)

Background

TBI epidemiology by GCS.
  • Also known as Traumatic Brain Injury (TBI): Impairment in brain function from a mechanical force

TBI Pathophysiology

Primary injury

Secondary injury

Brain swelling causes increased ICP which compresses the tissue causing ischemia with direct compression of the vasculature causing brain tissue herniation and brain death

  • Leads to expansion of the original injury (predominantly metabolic insult)
    • Calcium and sodium shifts
    • Mitochondrial damage
    • Production of free radicals
  • Ultimately leads to damage to axonal integrity and axonal transport
    • Enzyme activity leads to apoptosis
  • Microscopic structural injury is often unidentifiable on CT or MRI

Cerebral Blood Flow and Autoregulation

  • vasoconstriction
    • HTN, Hypocarbia, alkalosis
  • No good way to measure cerebral blood flow
    • Use CPP as surrogate
      • CPP is amount of pressure needed to perfuse the brain
      • CPP=MAP-ICP
        • When ICP elevates, CPP decreases
        • Normal ICP
          • 15 in adults
          • <10 to 15 in children
          • 1.5 to 6.0 in infants
  • Autoregulation allows the body to control the cerebral blood flow
    • Autoregulatory mechanism is damaged in most TBI patients

Clinical Features

  • Adult patient with blunt head trauma

Differential Diagnosis

Head trauma


Neck Trauma

Evaluation

Adult GCS

Eye Opening Verbal Motor
6: Obeys commands
5: Oriented 5: Localizes to pain
4: Spontaneously opens 4: Confused speech 4: Withdraws from pain (normal flexion)
3: Opens to command 3:Inappropriate words 3: Decorticate posturing (abnormal flexion)
2: Opens to pain 2: Incomprehensible sounds 2: Decerebrate posturing (extension)
1: Does not open 1: No response 1: No response
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe

Workup

Workup is dependent on GCS severity, see:

Management & Disposition

Dependent on underlying diagnosis, see:

Calculators

Glasgow Coma Scale (GCS)

Glasgow Coma Scale Calculator
Component Response Points
Eye Opening (E) Spontaneous +4
To verbal command +3
To pain +2
No eye opening +1
Verbal Response (V) Oriented +5
Confused +4
Inappropriate words +3
Incomprehensible sounds +2
No verbal response +1
Motor Response (M) Obeys commands +6
Localizes pain +5
Withdrawal from pain +4
Flexion to pain (decorticate) +3
Extension to pain (decerebrate) +2
No motor response +1
GCS Score / 15
Interpretation
13–15 Mild brain injury
9–12 Moderate brain injury
3–8 Severe brain injury — consider intubation if unable to protect airway
References
  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet. 1974;2:81-84. PMID 4136544.
  • Teasdale G et al. The Glasgow Coma Scale at 40 years. Lancet Neurol. 2014;13:844-854. PMID 25030516.


Canadian CT Head Rule

Canadian CT Head Rule
High Risk (for neurosurgical intervention)
Criteria No Yes
GCS <15 at 2 hours after injury 1
Suspected open or depressed skull fracture 1
Any sign of basal skull fracture (hemotympanum, raccoon eyes, CSF otorrhea/rhinorrhea, Battle sign) 1
Vomiting ≥2 episodes 1
Age ≥65 years 1
Medium Risk (for brain injury on CT)
Amnesia before impact >30 min 1
Dangerous mechanism (pedestrian struck, occupant ejected, fall from ≥3 feet or ≥5 stairs) 1
High Risk Criteria / 5
Medium Risk Criteria / 2
Interpretation
All No CT NOT required — Low risk for clinically important brain injury. Safe for discharge with head injury instructions.
Medium risk ≥1 CT recommended — Risk of brain injury on CT. Imaging indicated.
High risk ≥1 CT required — High risk for neurosurgical intervention. Urgent CT head.
References
  • Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. PMID 11356436.
  • Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511-1518. PMID 16189364.
  • Inclusion criteria: GCS 13-15, age ≥16, injury within 24 hours, witnessed LOC/amnesia/disorientation.

See Also

References

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