SEVERE HEAD INJURY

RESUSCITATION

Airway - intubate if GCS < 8
Breathing - ventilate if hypoxic or  inadequate ventilation (acute respiratory acidosis)
Circulation - control all sites of bleeding (including scalp laceration), maintain normotension
Disability - treat hypoglyscaemia

Avoid Nasal ETT/NGT in basal skull#

ONGOING MANAGEMENT

• Maintain head up 30 degrees
• Sedate with midazolam/mophine 1-20mg/hr (bolus 1-5 mg @ 5 min), Consider paralysis only if former causes haemodynamic instability despite fluids
• Keep pCO2 between 35-40 mmg Hg
• Maintain normotension (MAP at least 100mg Hg) - treat cause, fluids +/- inotropes
• Maintain normothermia./Mild hypothermia
• Steroids (no role)

MANAGE COMPLICATIONS

Incipient herniation (rapidly deteriorating GCS, evolving focal signs, Cushing's reflex - bradycardia/hypertension, respiratory arrest)

• Hyperventilate to pCO2 25mmHg
• Mannitol 25% (250 mg/ml) 0.25g/kg = 4ml/kg

DIC (elevated XDP/FDP/D-dimer, decreased fibrinogen, decreased platelet)

• FFP
• Platelets

Seizures

• Midazolam 5-10mg bolus IV
• Phenytoin 18mg/kg loading IV

Neurogenic pulmonary oedema

• IPPV + CPAP
• +/- inotropes

(GTN/frusemide generally not required)

INVESTIGATIONS

Urgent CT brain

SURGICAL MANAGEMENT

ICP monitoring

if GCS < 8 and

• Abnormal CT brain
• Age > 40, focal signs, SBP < 90 mmHg)
• Paediatric patients

Clot evacuation (if bleed)

Elevation of bone fragment (if depressed skull #)

Ventricular shunt (if acute hydrocephalus)