Rosen & Barkin's 5-Minute Emergency Medicine Consult (316 page)

• Determine the weapon type or caliber of weapon at scene.
  
• Loss of consciousness (LOC) or amnesia for event
  
• Use of anticoagulants
  
• Headache, visual changes, or hearing loss
  
• Focal neurologic complaints
  

• Evaluation of head for evidence of penetrating injury and if a projectile, for multiple sites
  
• Complete neurologic exam
  
• Alteration in level of consciousness and neurologic exam varies based on object and location.
  
• Evidence of penetrating injury to head
  

• Thorough history and exam to assess extent of injuries
  
• Imaging study
  

• CBC
  
• Platelet count
  
• Coagulation perimeters
  
• Type and cross-match
  
• Electrolytes, BUN, and creatinine baseline levels
  

• CT of head depicts location of lesion and extent of damage.
  
• Skull radiographs may reveal depth of impalement, location of bone fragments, and presence of fragments within the cranium.
  
• Cervical spine evaluation (when indicated):
  
  • Helical CT scanning or anteroposterior, lateral, and odontoid views plain radiographs
    

• Blunt head trauma
  
• Basilar skull fracture
  
• Any condition that alters mental status that may have induced a fall and caused secondary penetrating trauma
  

TREATMENT

• Stabilize but do not remove foreign object (e.g., knife).
  
• Determine the weapon type or caliber of weapon at scene.
  
• Protect and manage the airway to avoid hypoxemia.
  
• Avoid hyperventilation.
  
• Maintain cervical spine precautions.
  
• Transport to trauma center.
  
• Avoid hypoxia (oxygen saturation <90%):
  
  • 100% oxygen
    
• Avoid hypotension (systolic BP <90 mm Hg):
  
  • Administer IV crystalloid solutions
    

• Management of ABCs
  
• Rapid sequence intubation:
  
  • For Glasgow Coma Scale score <8, inability to protect airway, hypoxia, or cerebral herniation
    
  • Medications include etomidate or fentanyl as induction agent, succinylcholine (pretreat with minidose paralytic), rocuronium, or vecuronium; and morphine sulfate for ongoing sedation
    
  • Caution with fentanyl in the hemodynamically labile patient
    
  • Normalize Pco
    ₂
    . Avoid hyperventilation or hypoventilation.
    
• IV catheter placement
  
• Crystalloid solution to maintain systolic BP >90 mm Hg
  
• Address other sources of associated trauma.
  
• Cervical spine precautions should be maintained.
  

• Early neurosurgical consultation
  
• If patient has evidence of cerebral herniation (see Signs and Symptoms), initiate measures to decrease intracranial pressure:
  
  • Mild
    hyperventilation: 20 breaths/min in adults, 25 breaths/min in children, and 30 breaths/min in infants <1 yr to keep ETCO
    ₂
    about 30–35 mm Hg.
    
  • Elevate head of bed 20–30°.
    
  • Mannitol boluses IV: Do not administer mannitol unless systolic BP >100 mm Hg and patient is adequately fluid resuscitated.
    
• Phenytoin intravenously to prevent
  early
  post-traumatic seizures
  
• Reverse hypocoagulable states
  
• Glucocorticoids are
  not
  recommended to lower intracranial pressure in head trauma patients.
  
• Barbiturates are
  not
  recommended in the initial ED treatment.
  
• Transfuse as needed to keep hematocrit >30%.
  
• If definitive neurosurgical care is not immediately available, a single burr hole may preserve life until neurosurgical intervention can be attained:
  
  • Perform only in comatose patients with decerebrate or decorticate posturing who have not responded to initial treatment on the side of a known mass lesion/hematoma.
    
• Avoid hypothermia, which will increase risks of coagulopathy during surgery.
  
• Maintain NPO status.
  
• Surgery:
  
  • Based on clinical and radiologic findings and neurosurgical consultation
    

For RSI intubation, increased ICP, seizures, and pain control

• Etomidate: 0.2–0.3 mg/kg IV
  
• Fentanyl: 3–5 μg/kg IV:
  
  • If systolic BP >100 mm Hg
    
• Mannitol: 0.25–1 g/kg IV bolus
  
• Morphine sulfate: 2–20 mg IV (peds: 0.1 mg/kg up to adult doses)
  
• Phenytoin: 15–20 mg/kg IV up to 1,000 mg
  
• Rocuronium: 0.6 mg/kg IV
  
• Succinylcholine: 1–2 mg/kg IV
  
• Vecuronium bromide: 0.1 mg/kg IV:
  
  • Pretreatment minidose: 0.01 mg/kg IV
    
• Vitamin K:
  
  • To be used in patients on Coumadin with intracranial hemorrhage
    
  • 10 mg in 50 mL NS infused over 30 min
    
• Protamine sulfate:
  
  • To be considered if taking low molecular weight heparin (LMWH) with intracranial hemorrhage
    
  • If LMWH used <8 hr prior, use 1 mg protamine for each mg of LMWH slow IV push over 1--3 min
    
  • If LMWH used >8 hr prior, use 0.5 mg protamine for each mg of LMWH slow IV push over 1--3 min
    

FOLLOW-UP

Admit all patients to ICU or transport directly to surgery.

Do not discharge.

All patients with penetrating skull injuries should have been admitted.

• Failure to query about anticoagulant use and image appropriately
  
• Failure to aggressively reverse hypocoagulable states
  

• Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury 2nd edition.
  Prehosp Emerg Care
  . 2008;12(suppl 1):S1–S52.
  
• Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. XV. Steroids.
  J Neurotrauma.
  2007;24(suppl 1):S91–S95.
  
• Committee on Trauma.
  Head Trauma: Advanced Trauma Life Support
  . 8th ed. Chicago, IL: American College of Surgeons, 2008.
  
• Espinosa-Aguilar A, Reyes-Morales H, Huerta-Posada CE, et al. Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury.
  J Trauma
  . 2008;64(5):1327–1341.
  
• Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents—second edition.
  Pediatr Crit Care Med.
  2012;13(suppl 1):S1–S82.
  
• Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
  Chest.
  2012;141(suppl 2):e737S–801S.
  
• Warner KJ, Cuschieri J, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury.
  J Trauma
  . 2007;62(6):1330–1336.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Head Trauma, Blunt
  
• Spine Injury: Cervical, Adult
  

CODES

• 803.60 Other open skull fracture with cerebral laceration and contusion, unspecified state of consciousness
  
• 803.90 Other open skull fracture with intracranial injury of other and unspecified nature, unspecified state of consciousness
  
• 854.10 Intracranial injury of other and unspecified nature with open intracranial wound, unspecified state of consciousness
  

BASICS