Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 6 n Head Trauma
necessary for safe endotracheal intubation or obtaining
reliable diagnostic studies.
When a patient requires intubation because of
airway compromise, perform and document a brief
neurological examination before administering any
sedatives or paralytics.
Anesthetics, Analgesics, and Sedatives
Anesthetics, sedation, and analgesic agents should
be used cautiously in patients who have suspected
or confirmed brain injury. Overuse of these agents
can cause a delay in recognizing the progression of a
serious brain injury, impair respiration, or result in
unnecessary treatment (e.g., endotracheal intubation).
Instead, use short-acting, easily reversible agents at
the lowest dose needed to effect pain relief and mild
sedation. Low doses of IV narcotics may be given for
analgesia and reversed with naloxone if needed. Shortacting
IV benzodiazapines, such as midazolam (Versed),
may be used for sedation and reversed with flumazenil.
Although diprovan (Propofol) is recommended for the
control of ICP, it is not recommended for improvement in
mortality or 6-month outcomes. Diprovan can produce
significant morbidity when used in high-dose (IIB).
SecondARy Survey
Perform serial examinations (note GCS score, lateralizing
signs, and pupillary reaction) to detect neurological
deterioration as early as possible. A wellknown
early sign of temporal lobe (uncal) herniation
is dilation of the pupil and loss of the pupillary
response to light. Direct trauma to the eye can also
cause abnormal pupillary response and may make
pupil evaluation difficult. However, in the setting of
brain trauma, brain injury should be considered first.
A complete neurologic examination is performed
during the secondary survey. See Appendix G:
Disability Skills.
Diagnostic Procedures
For patients with moderate or severe traumatic brain
injury, clinicians must obtain a head CT scan as soon
as possible after hemodynamic normalization. CT
scanning also should be repeated whenever there is
a change in the patient’s clinical status and routinely
within 24 hours of injury for patients with subfrontal/
temporal intraparenchymal contusions, patients
receiving anticoagulation therapy, patients older
than 65 years, and patients who have an intracranial
hemorrhage with a volume of >10 mL. See Appendix
G: Skills — Adjuncts.
CT findings of significance include scalp swelling
and subgaleal hematomas at the region of impact.
Skull fractures can be seen better with bone windows
but are often apparent even on the soft-tissue
windows. Crucial CT findings are intracranial blood,
contusions, shift of midline structures (mass effect),
and obliteration of the basal cisterns (see n FIGURE 6-7).
A shift of 5 mm or greater often indicates the need
for surgery to evacuate the blood clot or contusion
causing the shift.
Medical TheRApies for
Brain Injury
The primary aim of intensive care protocols is to
prevent secondary damage to an already injured
brain. The basic principle of TBI treatment is
that, if injured neural tissue is given optimal
conditions in which to recover, it can regain
normal function. Medical therapies for brain
injury include intravenous fluids, correction of
anticoagulation, temporary hyperventilation,
mannitol (Osmitrol), hypertonic saline, barbiturates,
and anticonvulsants.
Intravenous Fluids
To resuscitate the patient and maintain normovolemia,
trauma team members administer intravenous
fluids, blood, and blood products as required.
Hypovolemia in patients with TBI is harmful.
Clinicians must also take care not to overload the
patient with fluids, and avoid using hypotonic fluids.
Moreover, using glucose-containing fluids can cause
hyperglycemia, which can harm the injured brain.
Ringer’s lactate solution or normal saline is thus
recommended for resuscitation. Carefully monitor
serum sodium levels in patients with head injuries.
Hyponatremia is associated with brain edema and
should be prevented.
Correction of Anticoagulation
Use caution in assessing and managing patients
with TBI who are receiving anticoagulation or
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