Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 6 n Head Trauma
n FIGURE 6-11 Algorithm for
Initial Management of Severe Brain
Injury. (Adapted with permission
from Valadka AB, Narayan RK,
Emergency room management
of the head-injured patient.
In: Narayan RK, Wilberger JE,
Povlishock JT, eds., Neurotrauma.
New York, NY: McGraw-Hill, 1996.)
box 6-2 priorities for the initial evaluation and triage of patients with severe
brain injuries
1. All patients should undergo a primary survey, adhering
to the ABCDE priorities. First assess the airway. If the
patient requires airway control, perform and document a
brief neurological examination before administering drugs
for intubation. Assess the adequacy of breathing next,
and monitor oxygen saturation.
2. As soon as the patient’s blood pressure (BP) is
normalized, perform a neurological exam, including GCS
score and pupillary reaction. If BP cannot be normalized,
continue to perform the neurological examination and
record the hypotension.
3. If the patient’s systolic BP cannot be raised to > 100 mm
Hg, the doctor’s first priority is to establish the cause
of the hypotension; the neurosurgical evaluation takes
second priority. In such cases, the patient should undergo
focused assessment with sonography for trauma (FAST)
or diagnostic peritoneal lavage (DPL) in the ED and may
need to go directly to the OR for a laparotomy. Obtain
CT scans of the head after the laparotomy. If there is
clinical evidence of an intracranial mass, diagnostic burr
holes or craniotomy may be undertaken in the OR while
the celiotomy is being performed.
4. If the patient’s systolic BP is > 100 mm Hg after
resuscitation and there is clinical evidence of a possible
intracranial mass (e.g., unequal pupils or asymmetric
results on motor exam), the highest priority is to obtain
a CT head scan. A DPL or FAST exam may be performed
in the ED, CT area, or OR, but do not delay the patient’s
neurological evaluation or treatment.
5. In borderline cases—such as when the systolic BP can be
temporarily corrected but tends to slowly decrease—
make every effort to get a head CT before taking the
patient to the OR for a laparotomy or thoracotomy. Such
cases call for sound clinical judgment and cooperation
between the trauma surgeon and neurosurgeon.
ventilation parameters to maintain a PCO2 of approximately
35 mm Hg. Reserve hyperventilation acutely
in patients with severe brain injury to those with
acute neurologic deterioration or signs of herniation.
Prolonged hyperventilation with PCO 2
< 25 mm Hg is
not recommended (Guidelines IIB).
Circulation
Hypotension usually is not due to the brain injury
itself, except in the terminal stages when medullary
failure supervenes or there is a concomitant
spinal cord injury. Intracranial hemorrhage cannot
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