Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ GCS < 9 or a motor scale < 5 = severe traumatic brain injury9 < GCS ≤ 13: “moderate” but beware! Treat like a severe traumatic brain injury until proved otherwiseGCS 14–15: minor head injuryBeware of “talk-and-deteriorate” patients, whose GCS drops within 48 hours. Usually subdural or extra-dural hematoma +++ Airway ++ C-collar until C-spine “cleared” (see trauma chapter)Tracheal intubation (in-line stabilization, or even fiberoptic)Unclear whether prehospital intubation improves outcomeAvoidDecreases in MAP during intubation: use RSI with succinylcholine and ketamine or etomidate. Control MAP strictly. Use ephedrine or norepinephrine if necessaryAlso avoid large increases in MAP during intubation: topical lidocaine, “soft hands”, IV esmolol if needed +++ Breathing ++ Ventilation for SpO2 > 95% and ETCO2 = 35 mm Hg +++ Circulation ++ Insert A-lineBring MAP > 80 mm Hg with isotonic crystalloids (fluid will not increase ICP in a hypotensive TBI patient)If needed, initiate norepinephrine infusion through a CVLBring Hb > 8 g/dLIf severe hemorrhage due to other lesions, emergent surgical hemostasis might be necessary +++ Neuro ++ Sedation-analgesia by midazolam (also prevents initial seizures) and opioids as infusionEmergent CT-scan without contrast; neurosurgery involvement depending on resultsFixed dilated pupil (uni- or bilateral) = emergency, incipient herniationNeurosurgical consult STATAcute hyperventilation to PaCO2 of 25 mm HgMannitol 20% 2 mL/kg in 10 minutes IV or 7.5% hypertonic saline (HSS) 125 mL IV en route to CT-scanIf the pupils are still fixed and dilated, repeat mannitol 20% 4 mL/kgPatient on warfarinGive prothrombin complex concentrate (PCC 1 mL/kg) or 25 IU/kg factor IXGive Vitamin K 10 mg IVIf possible, perform transcranial Doppler (TCD) of MCANormal values: PI < 1.4 and Vd (diastolic velocity) > 20 cm/sIf abnormal, consider increasing MAP and Hb, administering mannitol or HSS ++ Immediately if GCS < 15 or GCS = 15 but associated injuries or patient on warfarinDelayed at 6 hours after the trauma if GCS 15 with initial loss of consciousnessRepeat CT-scan if any neurological deteriorationRepeat CT-scan after 6 hours if normal initially (in 20% of patients with initially normal CT scans, the repeat scan performed beyond the 6th hour is abnormal) ++ Prevent secondary injury (ischemic, metabolic, excitatory neurotransmitters, reperfusion)Maintain a cerebral perfusion pressure above 60 mm Hg (CPP = MAP − ICP)Monitor ICP if possible; see Chapter 98Maintain normocapniaMaintain normal osmolarity (290–300 mmol/l). Avoid dextrose or hypotonic fluidsSeizure prophylaxis: fosphenytoin 13–18 phenytoin equivalents/kgDepending on underlying lesion:Neurosurgery if indicated (extra-dural/subdural hematoma, ventriculostomy, craniectomy if uncontrollable increase in ICP)Factor VIIa if persistent intra-cranial bleeding; controversial, very expensive ++ GCS 15 without warfarin, loss of consciousness or associated injury: no CT-scan, send home with monitoring instruction sheetGCS 15 with ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth