Head trauma is one of the most common reasons for admission to the emergency department. It is more common in pediatric patients. During the first admission to the emergency department, the examination, follow-up and treatment process is shaped by the history and physical examination findings. In this process, the presence of clinically significant traumatic brain injury (cTBI) is investigated in patients.
Fast stabilization and transport in the first pre-hospital evaluation will benefit the patient in terms of mortality and morbidity. In the first evaluation of the patient, circulatory control begins with restricting cervical movement and ensuring airway control. If necessary for the patient's airway, an airway is installed. There are contradictions as to whether it is absolutely necessary to intubate the patient, but in case of intubation, it is recommended to avoid hyperventilation [1].
The severity of head trauma is determined by history and physical examination during the patients' first admission to the emergency department, but sometimes intracranial trauma is diagnosed in patients. pathology may produce little or no clinical findings or no findings [1]. Head injury severity is classified according to the Glasgow Coma Score (GCS) as 14 and 15 as mild, 9 to 13 as moderate, and 8 and below as severe head injury. GCS has differences in children and adults (Table 1).
STORY
The following should be questioned and observed at the patient's first admission to the emergency department:
- Seizure
- Confusion, loss of consciousness
- Presence of headache, its severity and change in severity over time
- Vomiting, its form, number and content
- Abnormal behavior of the person responsible for care of children under two years of age
- Serious mechanism of trauma (fall from height, traffic accident, penetrating injury, etc.)
- Medical history of serious head trauma sequelae, operation history, bleeding disorder, arteriovenous malformation history, etc.
- Last medication intake and alcohol status
PHYSICAL EXAMINATION
During the physical examination, the patient's state of consciousness and visible pathologies are also examined manually, and the following findings are investigated:
- Disruption of consciousness GCS evaluation
- Focal neurological pathological finding
- Skull base fracture findings (periorbital edema, Battle's sign, hemotympanium, otorrhea, rhinorrhea)
- Subcutaneous hematoma, tenderness, signs of depression fracture
- Fontane bulge, opening, bleeding findings in children with open fontanel
MINOR HEAD TRAUMA
Since the application method and reasons may vary depending on age, it would be a more accurate approach to define mild head trauma according to age.
Under 2 years of age Patients with blunt head trauma who were awake or arousable by light sound or touch were defined as having mild head trauma [2]. In these patients:
- Clinical evaluation is difficult
- Intracranial pathologies are often asymptomatic
- Skull fractures and cTBI may occur even with minor trauma
2 years of age and overdefined as patients with a GCS of 14-15 at the first examination and no pathology detected in the history and physical examination [3].
MODERATE SEVERE TRAUMATIC BRAIN INJURY
Usually short-term loss of consciousness, disorientation and vomiting. In mild head injuries, the GCS score measured 30 minutes after the trauma is between 13-15, in moderate head traumas, the GCS score is generally between 9-12, and in severe injuries, the GCS is 8 and below [4].
CONCUSSION
It is defined as brain dysfunction due to post-traumatic brain damage that cannot be demonstrated by standard imaging methods. It is considered a mild brain injury [5].
TRAUMATIC BRAIN DAMAGE OF CLINICAL SIGNIFICANCE (cTBI)
- Epidural hematoma, subdural hematoma, cerebral contusion findings on brain computed tomography and one or more of the following
- Intervention by neurosurgeon (surgical or intracranial pressure monitoring)
- Head Endotracheal intubation for trauma intervention
- Hospitalization for at least 48 hours due to head trauma
- Death
- Skull compression fracture
- Skull base fracture findings (periorbital edema, Battle's sign, hemotympanium, otorrhea, rhinorrhea)
RADIOGRAPHIC IMAGING
While brain computed tomography is recommended for moderate and severe head trauma, tomography is recommended with certain criteria for minor head trauma [4, 6-8]. Although there is no common opinion for radiological imaging in head trauma, generally accepted approaches are as follows:
Situations that definitely require imaging with computed tomography:
- Presence of focal neurological findings
- Signs of child abuse
- Skull depression fracture or skull base fracture findings
- Impairment of consciousness
- Swelling of the fontanel
- Repeated vomiting attacks
- Post-traumatic seizure
- Suspicion of clinically significant traumatic brain injury (cTBI)
In case of deterioration after 4-6 hours of observation or when imaging with computed tomography is required at the time of admission:
- Loss of consciousness lasting less than a few seconds or imprecision of imitation of loss of consciousness
- Transient lethargic state
- Vomiting that the person can control
- Behavioral change described by caregiver
- Scalp hematoma
- Serious trauma mechanism (falling from a distance of more than 1 m, being thrown from the vehicle, a dead person in the vehicle, rolling)
- Occurred before 24 hours Skull fracture after head trauma It would be correct to decide in favor of imaging if the patient's condition worsens and vomiting continues [7, 9, 10]. New Orleans and Canadian CT decision rules are the most commonly used criteria in adults (Table 2). Additionally, the PECARN (Pediatric Emergency Care Applied Network) algorithm, which can be used in pediatric patients under the age of 2 and above, is shown in Figure 1.
The use of direct radiography in head trauma in clinical practice. month is discussed. Although it is thought to be superior to computed tomography, especially in horizontal linear fractures, studies have shown that high-resolution, normal resolution and three-dimensional computed tomography have high sensitivity and specificity in fracture detection [11, 12]. For this reason, it has been stated that the use of direct radiography will be useful in determining the location and size of foreign objects that cause reflection in tomography [5].
THINGS TO BE CONSIDERED DURING THE EMERGENCY SERVICE
AIRWAY AND BREATHING
Patients with a GCS value of 8 or less should be intubated quickly. During intubation, rapid serial intubation should be applied classically. Induction and blocking medical agents that can be used in rapid serial intubation are as follows [1]:
Drugs that can be used for induction (sedative, hypnotic)
Etomidate ; 0.3 mg/kg IV
Propofol; 1-3 mg/kg IV
Neuromuscular blocking drugs (long-acting drugs are not recommended in patients with TBI)
Succinylcholine; 1.0-1.5 mg/kg IV
Rocuronium; 0.6-1.0 mg/kg IV
MEDICAL TREATMENT
Normal intracranial pressure is below 20 mmHg. In case of signs of increased intracranial pressure, the patient should first be carefully ventilated, the PaCO2 level should be kept between 35-40 mmHg and the oxygen saturation should be kept above 95% [1]. During this time, the patient's head should be elevated up to 30º. If the patient does not have hypotension, mannitol infusion can be given. Mannitol effect begins within 30 minutes and continues for 6-8 hours. Mannitol is applied in repeated doses at a dose of 0.25-1 g/kg, continuous infusion is not recommended. Fluid intake and excretion of the patient under mannitol treatment should be monitored.
In the presence of penetrating skull injury, major contamination or CSF leak, antistaphylococcal antibiotic prophylaxis such as ceftriaxone (2 g IV) should be administered.
GCS 8 Intracranial pressure monitoring is useful in the follow-up of the patient in cases of intracranial bleeding at or below. is taken; Intracranial pressure can be monitored with the help of a catheter inside the ventricle.
In case Cushing Reflex (Bradycardia + Hypertension + Bradypnea) is observed, it should be considered that there may be an increase in intracranial pressure and invasive procedures should be performed for pressure measurement. Other findings of increased intracranial pressure:
- Headache
- Neck stiffness
- Photophobia
- Disorder of consciousness
- Persistent vomiting
- Cranial nerve disorder
- Papilledema
- Cushing reflex
- Decorticated or decertified posture
In patients with impaired consciousness, frequent pupil examination and pupillary reflex monitoring should be performed.
- Fixed dilated pupil
- Uncal herniation (hematoma on the same side) → Emergency Operation
- Bilateral fixed dilated pupil
- Hypoxemia
- Bilateral uncal herniation
- Drug or substance effect
- Bilateral pinpoint pupil
- Pontine lesion
- Opiate use
discharge and RECOMMENDATIONS
What is normal at the first examination in the emergency department or during follow-up When patients progressing towards recovery are asymptomatic, it is necessary to explain to the patient and their relatives the issues that need to be taken into consideration in the early period after head trauma before being discharged. If possible, information documents should be provided for patients. Patients are advised to re-apply to the hospital in case of recurrent headache, weakness, dizziness, dizziness, decreased concentration, memory problems, sleep disorders, restlessness, weakness, visual disturbances, decision-making problems, depression and anxiety.
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