- Head injury is the #1 killer the trauma patient
To scan or not to scan?
- Head CT = $2700
Occult Injury Issues
If GCS = 14, 10-20% + head CT
If GCS 13 = 20-30% + head CT
So, if GCS is not 15... risk increases substantially.
2 classes of head trauma patients:
New Orleans Head CT rule - goal was to identify all patients with abnormal scan.
Canadian Head CT rule - looking for clinically significant findings - more specific
Use with caution in drunk folks!
Anticoagulation is the Enemy!
IMAGE ALL ANTICOAGULATED HEAD TRAUMA
-- Much higher mortality in anticoagulated patients when compared to age matched controls
Plavix vs Coumadin?
-- Observational study of adult ED patients with blunt head trauma on coumadin vs plavix
-- higher risk of immediate bleed in plavix
-- important - 60% of people with bleeds had GCS 15 and 70% had no LOC
-- Risk of delayed bleed relatively small;
-- People with negative head CT who are THERAPEUTICALLY anticoagulated can be DC'ed home
-- People who are supra-therapeutic likely need observation.
Blood in the Brain is Bad.
Airway management - want to minimize increased ICP
> Lidocaine - theoretically is supposed to attenuate cough reflex but hasn't been proven to change outcomes
> Sucyincholine - can use without concern of worsening ICP from fasiculations
> Ketamine - is ok to use in ICP - good literature that ketamine can help with ICP and avoids risk of hypotension that can occur with etomidate (don't use if has history of obstructive hydrocephalus) - use 1-2mg/kg
Ventilator settings - RR of 12
Mannitol: 1g/kg (0.5g/kg - 1.5g/kg) - some evidence higher doses are more effective.
The Primary damage has been done... your job is to Prevent Secondary Injury
IMPENDING HERNIATION (and briefly in conjunction with other measures); endpoint 30 mm Hg
d. Steroids, narcan, hypothermia - none has been proven to work
* No fantastic evidence in people on ASA with head trauma*