Initial Diagnosis and Treatment -- Head Injuries
The first priority for the head-injured patient is complete and rapid physiologic resuscitation.
Most minor injuries will regain normal consciousness in the field or emergency department, and if the patient has normal neurological findings on examination and neuroradiological studies when appropriate, he/she may be discharged home with close supervision for the initial twenty-four hours.
Sedation and neuromuscular blockade can be useful in optimizing transport of the head injury patient. However, both treatments interfere with the neurological examination.
Initial Diagnosis
In addition to a physical examination by a practiced practitioner, the following should be part of the process to determine the initial diagnosis in a head-injured patient:
Glasgow Coma Scale Score
The Glasgow Coma Scale (GCS) when performed in the emergency department may aid in predicting the level of traumatic brain injury. Individuals with mild traumatic brain injuries may have a normal score on the GCS. Serial GCS scores may be helpful when intoxication may be a factor.
Neurological Examination
A neurological examination and neuropsychological assessment should be performed by a qualified practitioner to evaluate central nervous system function and diagnose specific behavioral or cognitive deficits or disorders.
Imaging
Computed axial tomography (CT) is a well-established, non-invasive brain imaging x-ray study that should reveal the presence of blood, skull fracture, and/or structural changes in the brain. It should be performed on all patients sustaining a transient neurologic deficit secondary to trauma.
Magnetic resonance imaging (MRI) scans are more sensitive than CT for detecting traumatic cerebral injury. Initially, MRI scans are clinically useful in the following situations to:
- Determine neurological deficits not explained by CT
- Evaluate prolonged interval of disturbed consciousness
- Define evidence of acute changes super-imposed on previous trauma or disease
Lumbar Puncture
Lumbar puncture (LP) is a well-established diagnostic procedure for examination of cerebrospinal fluid (CSF) in neurological disease and injury. The procedure should be performed by qualified and trained physicians under sterile conditions.
Indications for LP:
- Neurological disease and injury with no radiographic evidence of extra-axial hemorrhage, mass effect, or impending brain herniation
- With suspected or known increased intra-cranial pressure, LP should be preceded by fundoscopic examination and by a CT scan or MRI.
- Adult patients with headache exhibiting signs of increased intracranial pressure including papilledema, absent venous pulsations on funduscopic examination, altered mental status, or focal neurologic deficits should undergo a neuroimaging study before having a LP.
Contraindications for LP:
- Acute trauma to the spinal column
- Certain infections
- Increased intracranial pressure due to space occupying lesions
- Some coagulation disorders or defects
- Cutaneous infections in the region of the puncture site
- If CT or MRI shows intracerebral, intra-ventricular, or subarachnoid blood, LP should be withheld until neurological consultation is obtained.
Official Disability Guidelines (ODG) Return-To-Work Pathways
Concussion
Mild concussion: 3 to 7 days
Severe concussion, non-cognitive/modified work: 14 days to indefinite
Severe concussion, cognitive work: 84 days to indefinite
Skull fracture
Without brain injury, clerical/modified work: 7 days
Manual work: 21 days
Heavy manual work: 49 days
(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in Procedure Summary of the original guideline document)
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Initial Management
Hypotension
Hypotension (systolic blood pressure [SBP] <90 mm Hg) or hypoxia (apnea, cyanosis, or an oxygen (O2) saturation <90% in the field or a PaO2 <60 mm Hg) must be monitored and scrupulously avoided, if possible, or corrected immediately in severe traumatic brain injury patients.
- Mean arterial blood pressure should be maintained above 90 mm Hg through the infusion of fluids throughout the patient's course to attempt to maintain cerebral perfusion pressure (CPP) greater than 60 mm Hg.
- Patients with a Glasgow Coma Scale score less than 9, who are unable to maintain their airway or who remain hypoxemic despite supplemental O2, require that their airway be secured, preferably by endotracheal intubation.
Hypertension
If there are signs of transtentorial herniation or progressive neurological deterioration (not attributable to extracranial explanations), assume that intracranial hypertension is present and treat it aggressively. Hyperventilation should be rapidly established.
Hyperventilation
In the absence of increased intracranial pressure (ICP), avoid unnecessary or prophylactic hyperventilation (PaCO2 less than 26), in the first 24-hours after injury.
Hyperventilation therapy may be necessary for brief periods when there is:
- Acute neurologic deterioration not attributable to systemic pathology (i.e., hypotension)
Hyperventilation therapy may be necessary for longer periods if there is:
- Intracranial hypertension refractory to sedation
- Paralysis
- Cerebrospinal fluid drainage
- Osmotic diuretics
Intracranial Pressure
Intracranial pressure should be monitored in all patients with severe head injury following an abnormal CT scan. Abnormal findings may include one or more of the following:
- Hematomas
- Contusions
- Edema
- Compressed basal cisterns
In the absence of abnormal CT findings, ICP should also be monitored if two or more of the following are noted at admission:
- Patient is over 40 years old
- Unilateral or bilateral motor posturing
- Systolic blood pressure of less than 90 mm Hg
Interpretation and treatment of ICP should be corroborated by frequent clinical examination and cerebral perfusion pressure (CPP) data. In general, it is desirable to:
- Maintain ICP less than 20 to 25 mm Hg.
- Maintain mean arterial pressure (MAP) above 90.
- Maintain CPP (MAP at head level minus ICP) at or above 70 mm Hg.
Mannitol in doses ranging from 0.25 g/kg to 1 g/kg body weight is effective for control of raised ICP after severe head injury.
Mild or moderate head injury does not need to be monitored for ICP unless the conscious patient has traumatic mass lesions.
Cerebral Perfusion Pressure (CPP)
CPP should be maintained at a minimum of 60 mm Hg (60 to 70). In the absence of cerebral ischemia, aggressive attempts to maintain cerebral perfusion pressure above 70 mm Hg with fluids and pressors should be avoided because of the risk of adult respiratory distress syndrome.
Nutrition
Nutritional support should be aggressively initiated as soon as practicable. Preferable route is jejunal by gastrojejunostomy.
Anticonvulsants
Anticonvulsant treatment may be used to prevent early posttraumatic seizures in the high-risk individual, and are usually administered for one week in those with intracranial hemorrhage.
Prevention of early seizures has no statistically significant impact on long-term outcome or the development of late seizures or chronic epilepsy although the prevention of early seizures usually helps to reduce seizure-associated complications during acute management.
Operative Procedures
Craniectomy
Recommended for diffuse brain swelling, midline shift, and/or elevated ICP refractory to medical management and not fully alleviated by evacuation of mass lesion/hematoma (or in the absence of mass lesion/hematoma) -- (bone flap stored in freezer, or in the individual's abdominal wall).
Craniotomy
If there is immediate onset of total facial paralysis (uncommon) or if the electroneuronography (EnoG) shows greater than 90% degeneration of the facial nerve, exploration of the path of the facial nerve is indicated. This usually involves a middle fossa craniotomy and mastoidectomy in order to completely decompress the facial nerve.
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ODG Return-To-Work Pathways
Without neurologic deficit, medical treatment: 14 days
Aneurysmectomy, clerical/modified work: 28 days
Aneurysmectomy, manual work: 42 days
Craniectomy, clerical/modified work: 28 days
Craniectomy, manual work: 42 days
Craniotomy, clerical/modified work: 28 days
Craniotomy, manual work: 42 days
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Long-term Management
Postconcussion Syndrome
Approximately 38% of patients who sustain head trauma characterized by a brief disturbance of consciousness and clinically unremarkable neuroradiologic findings meet International Classification of Diseases 10th edition (ICD-10) diagnostic criteria for postconcussion syndrome (PCS). Symptoms could involve complaints of irritability, fatigue, headache, difficulty concentrating, dizziness and memory problems. Anxiety and depression are also frequently present, especially later in its course.
Although PCS has often been thought to reflect a psychological response to injury, there is considerable recent evidence to suggest that it is primarily a physiologic disturbance. For most individuals, treatment consists primarily of education of the patient and his/her family, along with supportive counseling regarding emerging problems at work or at home. A subgroup of patients, however, may require psychopharmacologic intervention. Avoid attempts of multiple parallel processing in a postconcussive stage.
Widely accepted treatments for post-traumatic headache may include, but are not limited to, interdisciplinary treatment, pharmacology, joint manipulation, physical therapy, massage, acupuncture, biofeedback, psychotherapy, and diet. These procedures should only be continued if functional gains are documented.
Electroencephalography (EEG)
Electroencephalography is not generally indicated in the immediate period of emergency response, evaluation, and treatment. Following initial assessment and stabilization, the individual's course should be monitored. If during this period there is failure to improve, or the medical condition deteriorates, an EEG may be indicated to assist in the diagnostic evaluation.
Physical Therapy
Patient rehabilitation after traumatic brain injury is divided into two periods: acute and subacute. In the beginning of rehabilitation, physical therapist evaluates patient's functional status; later he uses methods and means of treatment and evaluates effectiveness of rehabilitation. Early ambulation is very important for patients with coma. Physical therapy consists of prevention of complications, improvement of muscle force and range of motions, balance, movement coordination, endurance, and cognitive functions. Early rehabilitation is necessary for traumatic brain injury patients and use of physical therapy methods can help to regain lost functions and to return to society.
