Management of Severe
Head Trauma in A&E
Dr. David Tran
A&E department
FVHospital
17 mars 2010
Management of head injury

Primary survey: ensure that airways,
breathing, circulation and cervical spine
are secure.

Assessment of mental state (glasgow
score adapted to the age)

Alert (A), responds to voive (V),
Responds to pain (P), unresponsive (U)
Perform secondary survey

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
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Neck & cervical spine (tenderness, muscle
spasm)
Head: scalp hematoma, laceration,
swelling, tenderness…
Eyes: pupils size, equality, reactivity
Ears: otorrhage, hemotympan
Nose, mouth, facial fractures
Motor function: limbs, reflexes, lateralised
weakness, Babinski’s sign.
Seriousness of head trauma

Glasgow Score < or = 8 (severe head trauma)

Glasgow score 9-12 (moderate head trauma)

Glasgow score > or = 13 (mild head trauma)
Adapted Glasgow Coma Scale
Do not forget neck
protection

Severe head trauma are frequently
associated with neck injuries.

Those injuries often concern the cervicooccipital region (C1/C2)

Neck collar has to be put immediately at
arrival in A&E and will be removed only
after imaging.
General management

IV line, use infusion of isotonic solutions*
(NaCl 0.9% is the most adapted)
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Intubation: all patients with severe head
trauma (Glasgow score < or =8) have to
be intubated.

Crash induction is the gold standard for
management of airways.
* Avoid hypotonic solutions like G5% or Ringer Lactate
Induction / sedation
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Crash induction:
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Etomidate 0.3mg/Kg &
Suxamethonium 1mg/Kg
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Orotracheal intubation
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Immediate sedation with Hypnovel /

(becareful of the neck)
Fentanyl IV is very important to control
intracranial pressure
(continuous infusion following
protocole sedation in SMUR: 10 amp. Hypnovel /1 amp. Fentanyl)
Interest of early sedation in
case of severe head trauma
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Control agitation of the patient
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Control of analgesia
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Avoid or decrease intra-cranial
hypertension.

Adaptation to mechanical ventilation
Monitoring head trauma in A&E

Non invasive blood pressure/15 min
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SpO2
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Pulse rate on scope
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PCO2
(if not available, blood gaz during
mechanical ventilation)
Intracranial pressure
monitoring (PPC= MAP-ICP)

Each time there is a severe traumatic
brain injury (with GCS 3-8) associated
with CT scanner images of hematomas,
contusions, swelling, herniation or
compressed basal cisterns.
Head CT scanner abnormalities

Left Epidural
hematoma
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Effacement of left
ventricle

Shift >10mm of the
medium line
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Signs of ICH
Head CT scanner abnormalities (2)

Right Sub-dural
hematoma

Shift > 10mm of the
medium line
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Effacement of the
right ventricle
Head CT scanner abnormalities (3)

Frontal contusions
(hemorrhages)
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Effacement of the
cisterns and subarachnoid spaces
Head CT scanner abnormalities (4)
Hyperdense lesion
in R. frontal lobe
=
cerebral contusion
Biconvexity in the
left petrus temporal
= HED
CT scanner abnormalities (5)
Ventricles & subarachnoid spaces
obliterated = ICH
Sub-arachnoid
hemorrhage
CT Scanner abnormalities (6)
Sub-arachnoid
hemorrhage in
posterior fossa
Recommandations

Blood pressure should be monitored
and hypotension avoided

(Pas > 90mmHg)
Oxygenation should be monitored and
hypoxemia avoided
(Pa O2 > 60mmHg
SpO2>90%)

Mannitol is effective for control of
raised intra-cranial pressure (ICP)
Signs of intra-cranial
hypertension (ICH)

Signs of transtentorial herniation / ICH:
anisocoria, mydriasis, neurological lateral signs,
seizures, bradycardia, hypertension, bradypnea.

Progressive neurological deterioration not
attributable to extra-cranial causes.

Those signs are an indication for immediate
use of bolus of Mannitol
(up to 1mg/Kg/20 min.)
Use of Mannitol

Indication: Signs of intra cranial
hypertension

Mannitol 20 or 25%
(20g/100ml or
25g/100ml)
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Bolus 0.25 to 1g/Kg/20 min.

Exp: body weight 60 kgs > 15g
to 60g IV in 20 min. = 100 to
300ml Mannitol 20%
Administration of Mannitol

Mannitol is superior to Barbiturates for
control of high ICP after TBI.
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The osmotic effect of Mannitol is delayed
for 15-30 min. while gradients are
established between plasma & cells.

Its effects persist for about 90 min. to
several hours.
Use of hypertonic Saline (HS)

Osmotic mobilization of water across blood
brain-barrier. (Saline 7,2% or 10%)
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HS as a bolus infusion could be an effective
adjuvant to Mannitol to treat ICH.

Potential side effects: central pontic
myelinolysis in patient with chronic
hyponatremia.

More studies are required to determine the
place of HS in the treatment of ICH.
Goals for management of severe
head trauma

Any episode of hypotension or hypoxia
increases head injury mortality.

Systolic blood pressure > 90mmHg
(ideal = SBP 120mmHg & MAP 85mmHg )

SpO2 > 90% (PaO2> 60mmHg)
Management of severe
head trauma in A&E

Neck collar

Monitoring BP, pulse, SaO2

IV line and fluid infusion (NaCl 0.9%) to
restore systolic BP >90mmHg

Intubation (crash induction) and
mechanical ventilation.
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Immediate sedation after intubation
(hypnovel/fentanyl)
Interest of early CT scanner

CT scanner has to be performed before
transfert to neurosurgical center.

The time you spend to perform CT in FVH
(<15min.) is time you save for the patient
later. (timing in CR is probably longer)
Management of imaging

Head CT scanner without injection

Complete by images of cervico-occipital and
cervical region.
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Chest Xray and Pelvis Xray are systematic

Thorax, abdomen and dorso-lombar rachis
CT scanner are requested according clinical
signs.
Indication of early
neurosurgery
Neurosurgery in emergency