32 Critical Care Emergencies
SEVERE HEAD INJURYMANAGEMENT
1 Clear the airway by sucking out any secretions, remove loose or broken
dentures, and insert an oropharyngeal airway. Give 100% oxygen by tight-
fitting mask with reservoir bag. Aim for an oxygen saturation above 94%.
2 Immobilize the cervical spine by applying a semi-rigid collar, as up to 10% of
patients with blunt head trauma have a concomitant neck injury. Use
sandbags in addition on either side of the head taped to the forehead, unless
the patient is excessively restless.
3 The patient must be intubated to protect and maintain the airway, prevent
aspiration and guarantee oxygenation and ventilation, if the gag ref lex is
reduced or absent. Take great care to minimize neck movements by an assist-
ant providing in-line manual immobilization of the neck throughout.
(i) Call the senior ED doctor immediately.
(ii) Prepare for an RSI intubation (see p. 467).
4 Regularly repeat the temperature, pulse, blood pressure and respiratory rate.
5 Consider whether a tension pneumothorax (see p. 231), open pneumothorax
(see p. 220), massive haemothorax (see p. 231) or flail chest (see p. 232) is
responsible if the respiratory rate is rapid or ineffective.
6 Commence i.v. f luid to maintain normotension. Use a crystalloid such as
normal saline or Hartmann’s.
(i) Aim for a MAP of >90 mmHg, to ensure adequate cerebral
perfusion pressure.
(ii) Avoid excessive fluid administration if the patient is
normotensive, as this may contribute to cerebral oedema.
7 Search for associated injuries including chest, abdominal or pelvic bleeding,
long-bone fracture and cardiac tamponade if the patient is hypotensive. Note
shock is rarely due to an isolated head injur y:
(i) Occasionally, brisk scalp bleeding alone is found to be
responsible, usually in children.
(ii) Alternatively, a cervical or high thoracic spinal cord injury with
loss of sympathetic vascular tone may be the cause.
8 Treat the following complications immediately, as they worsen the existing
primary cerebral injury and may lead to secondary brain damage.
(i) Hypoglycaemia
(a) perform a bedside glucose test; if it is low, send a formal
blood glucose to the laboratory and give 50% dextrose 50 mL
i.v.
(b) remember this especially if the patient has been drinking
alcohol.