GUIDELINES FOR MANAGEMENT OF HEAD INJURY
Indications for admission
1. All patients in coma/ altered sensorium
2. Compound head injury ( exposed brain/CSF leak or CSF
rhinorrhea or pneumocephalous on X-ray/CT)
3. Compound skull fractures
4. H/O loss of consciousness / seizures/ repeated vomiting/severe
Headache
5. All unknown patients ( picked up from roadside – check
personal belongings for identification. Inform MS before
admission).GCS cannot be assessed (alcohol or other
intoxication)
6. Patients with doubtful history and no attendants
CASUALTY MANAGEMENT OF MODERATE /
SEVERE HEAD INJURY
Divided into 5 parts :
a) General assessment
b) Information dissemination
c) Initial treatment
d) Investigations
e) Documentation
f) Patient transfer
General Assessment
1. Check airway and respiration. SPO2. Clear airway if
reqd.
2. Vital parameters – pulse, BP, resp
3. Apply cervical collar ( Spondylosis collar – MGRM)
4. Neurological assessment: GCS, Pupillary reaction,
focal
5. neurological deficit, spine examination (only active
movements)
6. Examine chest, abdomen, pelvis and long bones
Information dissemination
1. Inform neurosurgeon and carry out part C and
D in consultation
2. Inform anaesthesiologist/ intensivist in ICU
Initial treatment
1. Start IV access with 2 lines on one upper limb ( Lt
preferably, keeping Rt for CVP line by
anaesthesiologist/intensivist)
2. Draw blood for hemogram, sugar, electrolytes, RFT,
blood grouping, LFT, coagulation profile
3. Parenteral analgesia ( Inj Diclofenac Sod ) for pain
relief , esp. if ass. long bone fractures.
4. Splint fractures to reduce pain
5. Catheterize patient
6. Drug herapy:
a) Mannitol 0.25 -0.5 gm /kg wt over 10 mins IV
b) IV Dilantin 15 mg/kg body weight slowly at
rate of 50 mg/min
c) Antibiotics ( Cefotaxime + Amikacin) in case of
compound head trauma
d) IV Emeset in case of vomiting
e) IV Pantocid 40 mg
7. Ryles tube to be passed in all severe head injury. In
case of nasal bleed, do not pass nasal tube
Investigations
1. NCCT head ( patient can be sedated if restless)
2. X-ray cervical spine
3. X –ray chest
4. Any other X-rays as clinically indicated
Documentation
Documentation is as important as management since
majority are medicolegal. However should be done only
after patient is stable and admitted. Brief notes on vital
parameters may be made to help.
1. MLC – most cases are of medicolegal nature and
after documentation, the police must be informed.
Enter the following info. in the MLC register:
a) Time info given to police
b) Name of constable
c) MLC number
Patient transfer
Whenever an intubated patient is transferred within
the facility (example, for CT) or between facilities,
the following must be available:
1. Anesthesiologist and one nurse must accompany
2. Patient should be on portable ventilator
3. Monitoring of heart rate, oxygen saturation and
NIBP
4. Resuscitation tray, ambu bag and oxygen
cylinder
Glasgow Coma Scale
E4 – eyes open spontaneously
E3 – eyes open on command
E2 – eyes open to painful stimuli
E1 – eyes do not open
(Ec – eyes closed (taped or because of marked periorbital edema)
V5 – oriented
V4 – disoriented
V3 - inappropriate words
V2 – incomprehensible sounds
V1 – no sounds
(Vet /Vtr – endotracheal tube/tracheostomy)
Glasgow Coma Scale Contd….
M6 – following commands
M5 – localizes pain
M4 – flexion to pain/withdrawal
M3 – abnormal flexion
M2 – extension to pain (decerebration)
M1 – no response
(Mp – motor response cannot be assessed as patient is
paralyzed)
Limitations
1. Gives no information on pupillary status
2. Gives no information on focal neurological deficit
GCS cannot be assessed
1. In children
2. In presence of shock/ hypoxia/hypothermia
3. Inpatients with coma due to metabolic causes
4. In patients with alcohol or other intoxication
Score 8 and below: Severe head injury
Score 9-12 : Moderate head injury
Score 13-15 : Minor head injury
Shock in Head Injury
Shock is rarely seen in head injury and usually implies major
trauma elsewhere such as chest injury /abdominal injury,
major long bone fractures or associated cervical spine injury
with quadriplegia.
In head injury, if shock occurs there is usually an obvious
source of major bleeding such as extensive skull lacerations
or profuse bleeding from skull base associated with fractures
and manifesting as nasal bleed. We must remember that
young children can have shock even with small scalp
lacerations.
It is reiterated that usually severe abdominal /chest trauma
producing shock takes precedence in management over the
head injury.
Deterioration in patient’s neurological
status after admission/ after receiving
from OT
Whenever a patient is received from casualty or from OT after cranial
surgery, detailed neurological examination must be made and
recorded. If different from admission notes, inform immediately.
An immediate assessment is vital as only then can we pick up
neurological worsening.
The causes of deterioration in the head injury patient/ postoperative
patient are:
1. The underlying pathology
2. Post operative hematoma
3. Hypoxia
4. Seizure
5. High grade temperature
6. Electrolyte disturbances
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