Monday, May 1, 2017

Managing Head Injuries

Head injury
can be defined as any alteration in mental or physical functioning related to a blow to the head. Loss of consciousness does not need to occur.

Head injury refers to trauma of the head. This may or may not include injury to the brain.

Acute Management
In the setting of acute head injury, give priority to the immediate assessment and stabilization of the airway and circulation.

Following stabilization, direct attention to prevention of secondary injury. Keep mean arterial pressures above 90 mm Hg; arterial saturations should be greater than 90%. Urgent CT scanning is a priority.

Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding. If the brain has been severely damaged by trauma, neurosurgical evaluation may be useful.

Monitoring Intracranial Pressure
Since elevated intracranial pressure is an independent predictor of poor outcome. If the intracranial pressure rises above 20-25 mm Hg, intravenous mannitol, CSF drainage, and hyperventilation can be used. Hypertonic saline has also been used in lieu of mannitol to lower intracranial pressure.

Nutritional support
Head injury induces a hypermetabolic state and early nutritional interventions may be as critical as cerebral perfusion pressure. Parental or enteral feedings reduced mortality by at least 50% in one study when given early in the course of severe head injury.

Advice on discharge
Patients who are discharged after mild head injury should be given an instruction sheet for head injury care. The sheet should explain that the person with the head injury should be awakened every 2 hours and assessed neurologically. Caregivers should be instructed to seek medical attention if patients develop severe headaches, persistent nausea and vomiting, seizures, confusion or unusual behavior, or watery discharge from either the nose or the ear.

Need for Sedatives
Sedation is often necessary in patients with traumatic injury. Some patients with moderate head injuries have significant agitation and require sedation. In addition, patients with multisystem trauma often have painful systemic injuries that require pain medication, and many intubated patients require sedation. Short-acting sedatives and analgesics should be used to accomplish proper sedation without eliminating the ability to perform periodic neurologic assessments.

Need for Surgery
In cases of a subdural hematoma surgical evacuation may be needed.

Decompressive craniectomies are sometimes advocated for patients with increased intracranial pressure refractory to conventional medical treatment.

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