Head Injury Management

1. Classification of TBI Severity

2. Primary Survey - ATLS Approach

• Intubate if GCS ≤8 or airway is compromised
• Target SpO2 ≥90% (PaO2 ≥60 mmHg); hypoxia is directly toxic to injured neurons
• Avoid prophylactic hyperventilation (PaCO2 <30 mmHg) - it causes vasoconstriction and worsens ischemia. Hyperventilation is reserved for acute herniation as a temporizing measure only

• Ages 15-49 or >70 years: maintain SBP >110 mmHg
• Ages 50-69 years: maintain SBP >100 mmHg
• A 10-point drop in SBP across the range 40-119 mmHg is associated with an 18.8% increase in in-hospital mortality (Brain Trauma Foundation, Level III)

• GCS score, pupillary response, lateralizing signs
• Cervical spine immobilization if indicated (high-energy mechanism, age >65, fall >3m, serious multi-trauma)

3. Imaging

• Non-contrast CT head is the first-line imaging modality for moderate/severe TBI
• Identifies epidural, subdural, subarachnoid hemorrhage, contusions, skull fractures, midline shift
• CT angiography if vascular injury is suspected
• Concussion: Routine CT/MRI is NOT indicated if GCS is 15 and there are no red flag features; structural imaging is normal in concussion

4. ICP Monitoring

• Severe TBI (GCS 3-8 after resuscitation) + abnormal CT scan
• Severe TBI + normal CT if patient is >40 years, shows motor posturing, or SBP <90 mmHg (Level III)

• Treat ICP when >20-22 mmHg
• Target Cerebral Perfusion Pressure (CPP) = MAP - ICP: range 60-70 mmHg
• Avoid aggressive attempts to raise CPP >70 mmHg (risk of ARDS)
• Avoid CPP <50 mmHg

5. Medical Management of Raised ICP

Hyperosmolar Therapy

• Mannitol: 0.25-1 g/kg IV - Level II evidence; first-line for acute ICP crises. Restrict use without ICP monitoring to those with signs of herniation
• Hypertonic saline: 3% at 2-5 mL/kg IV over 15 min for acute ICP crises (pediatric guideline); increasingly preferred in adults due to less diuresis-related hypotension

Sedation & Analgesia

• Propofol is recommended for ICP control (not for mortality benefit)
• Avoid fentanyl and midazolam boluses during ICP crises (can cause acute ICP spikes)
• High-dose barbiturates (pentobarbital/thiopental) for ICP refractory to all other measures - hemodynamic stability essential before use

Head Position

• 30-degree head-of-bed elevation reduces ICP
• Head neutral (avoid jugular venous compression)

Hyperventilation

• Target PaCO2 35-40 mmHg normally
• Brief hyperventilation to PaCO2 30-35 mmHg only as a bridge to definitive treatment during acute herniation

Temperature

• Fever must be actively controlled (antipyretics ± cooling); hyperthermia is toxic to injured neurons
• Prophylactic hypothermia is NOT recommended (no mortality benefit shown)

6. What NOT to Do - Contraindicated Therapies

7. Seizure Prophylaxis

• Levetiracetam (Keppra): 1g loading dose + 500mg twice daily x 7 days
• Reduces incidence of early post-traumatic seizures (within 7 days)
• No evidence supports long-term prophylaxis beyond 7 days
• Phenytoin is the historically studied agent, but Keppra is preferred in practice due to a better side-effect profile

8. Other Medical Management

• Mechanical (intermittent pneumatic compression stockings) - initiate immediately
• Low-molecular-weight heparin or unfractionated heparin may be added - reasonable to initiate 24 hours after hematoma deemed stable
• Risk-benefit analysis required; risk of hematoma expansion vs. PE/DVT

9. Surgical Management

• Surgical evacuation if >30 mL, >15mm thickness, or >5mm midline shift
• Emergency craniotomy if clinical deterioration (blown pupil, GCS drop)

• Acute SDH with thickness >10mm or midline shift >5mm: surgical evacuation
• Burr-hole drainage may suffice for chronic SDH

• Surgical if: significant mass effect, refractory ICP, or accessible location with neurological deterioration

• Open/compound depressed fractures need surgical elevation and debridement
• Closed depressed fractures: surgical if depression >thickness of skull, over eloquent cortex, or cosmetically significant

• For refractory elevated ICP not responsive to medical management
• Bifrontal or unilateral hemicraniectomy

10. Surgical Timing Consideration

11. Pediatric Considerations

• Target CPP >40 mmHg, ICP treatment threshold <20 mmHg
• Seizure prophylaxis with phenytoin or levetiracetam
• Bolus 3% hypertonic saline at 2-5 mL/kg for ICP crises
• Avoid fentanyl/midazolam boluses during ICP crises
• Concussion: no routine CT unless red flag features; return-to-play protocol is gradual

12. Brain Death Assessment

Summary Algorithm

Head Injury
    ↓
Primary Survey (ABCs) + C-spine control
    ↓
Correct hypotension (SBP >110) + hypoxia (SpO2 >90%)
    ↓
GCS + Neurological Exam + Non-contrast CT Head
    ↓
Mild TBI (GCS 13-15)          Moderate-Severe TBI (GCS ≤12)
↓                              ↓
Observation/discharge          ICU admission
(if CT normal)                 ICP monitoring (if GCS ≤8)
                               ↓
                    Medical: Mannitol/HTS, Keppra, head-up 30°,
                             normoglycemia, antipyretics, PPIs
                               ↓
                    Surgical if: mass lesion, herniation,
                                 refractory ICP

• Schwartz's Principles of Surgery, 11th Ed. - Management of Traumatic Brain Injury
• Sabiston Textbook of Surgery - Traumatic Brain Injury Management
• Bradley and Daroff's Neurology in Clinical Practice - Table 62.5, Guidelines for Severe TBI
• Rosen's Emergency Medicine - Box 160.8, Emergent Management of Severe TBI
• Morgan and Mikhail's Clinical Anesthesiology, 7th Ed. - Management Considerations for Acute TBI

Management of Seizures in Children

1. Definitions and Epidemiology

• Epilepsy is defined (ILAE) as: (1) ≥2 unprovoked seizures >24 hours apart; OR (2) one unprovoked seizure with ≥60% recurrence risk over 10 years; OR (3) diagnosis of an epilepsy syndrome
• ~1-1.5% of children will have a non-febrile seizure in their lifetime
• Febrile seizures are the most common seizure condition in pediatrics, occurring in ~4-5% of children aged 6-60 months

2. Seizure Classification (ILAE)

3. Febrile Seizures

Simple vs. Complex

Management of Simple Febrile Seizure

• Identify the source of fever - this is the primary workup
• No routine neuroimaging, EEG, or bloodwork required in a well-appearing, fully immunized child with normal neuro exam and no meningeal signs
• Lumbar puncture: NOT routinely indicated
  • Do consider LP if: <6 months of age, signs of meningitis, incomplete immunizations (H. influenzae type b, S. pneumoniae), pretreated with antibiotics
  • Children 6-12 months: consider LP if immunization status unknown
• Antiseizure medications: NOT required for a simple febrile seizure
• Recurrence risk: >33% - counsel family

Long-term AED Prophylaxis for Febrile Seizures

• Not recommended for simple febrile seizures
• Small increased risk (~2-5%, double the baseline) of developing afebrile epilepsy - family counseling is important

4. Acute Seizure Management (Active Seizure)

Immediate Priorities (All Seizures)

1. Position - lateral decubitus (recovery position) to prevent aspiration
2. Airway - nasopharyngeal airway if needed; avoid oral airways (risk of vomiting post-seizure)
3. Oxygen - by nasal cannula or face mask; bag-valve-mask if ventilation inadequate
4. C-spine protection if trauma suspected
5. IV/IO access - send glucose (bedside), electrolytes (Na, Ca, Mg), CBC, LFTs, AED levels, urine toxicology
6. Correct metabolic causes: hypoglycemia (D10W 5 mL/kg IV in children), hyponatremia, hypocalcemia, hypomagnesemia
7. Head-of-bed elevation if raised ICP is suspected

5. Status Epilepticus - Step-by-Step Protocol

Key principle: Every 10-minute delay in starting benzodiazepines is associated with higher death rates, longer seizure duration, and more complications.

Phase 1: Stabilization (0-5 minutes)

• ABCs + neurological exam
• Time the seizure from onset
• Oxygen, ECG monitoring
• Fingerstick glucose - if <60 mg/dL: D10W 5 mL/kg IV in infants/children
• IV/IO access + labs (electrolytes, hematology, toxicology, AED levels)

Phase 2: Initial Therapy (5-20 minutes) - Benzodiazepines (Level A)

• Rectal diazepam: 0.2-0.5 mg/kg (max 20 mg/dose) - Level B
• Intranasal midazolam - Level B (0.2 mg/kg IN; shown superior to rectal diazepam with more rapid onset)
• Buccal midazolam - Level B

• Child 1 month-<5 years: 0.2-0.5 mg/dose IV Q2-5 min, max total 5 mg
• Child ≥5 years: 1 mg/dose IV Q2-5 min, max total 10 mg

Second benzodiazepine dose: give only after 5 minutes of continued activity following first dose

Phase 3: Second-Line Therapy (20-40 minutes) - if seizure persists after 2 BZD doses

Fosphenytoin vs. Phenytoin: Fosphenytoin can be given 3x faster, is less cardiotoxic, less sclerosing, and can be given IM - preferred over phenytoin.

Phase 4: Third-Line / Refractory Status (40-60+ minutes)

• Refractory status epilepticus = failure of ≥2 adequate antiseizure drug doses
• Anesthetic doses with continuous EEG monitoring required:
  • Midazolam infusion OR
  • Propofol infusion (if intubated) OR
  • Pentobarbital / Thiopental OR
  • Ketamine (limited case-report evidence; may be effective vs. conventional anesthetics)
  • Inhalant anesthetics
• All cause apnea, hypotension, and depressed consciousness - intubation and hemodynamic monitoring mandatory
• Consult neurology for refractory pediatric status epilepticus

6. Long-Term AED Selection by Seizure Type

• Dravet syndrome (SCN1A mutation): Avoid lamotrigine - often worsens seizures
• Glucose transporter deficiency (SLC2A1): Responds to ketogenic diet

7. Breakthrough Seizures in Known Epilepsy

• Sub-therapeutic drug levels (child outgrew dose, vomiting, drug interactions, non-adherence) - check serum AED levels
• Febrile illness (lowers seizure threshold even with therapeutic levels)
• Sleep deprivation, stress

8. Special Situations

Seizures with Trauma

• Benzodiazepines remain first-line for active seizure
• Load with fosphenytoin or levetiracetam (not diazepam alone) to prevent short-term recurrence that can worsen TBI and raise ICP
• "Impact seizures" (within minutes of injury) do not increase risk of intracranial injury by themselves - but delayed seizures suggest more severe injury

Abusive Head Trauma

• Suspect in infants <2 years with seizures and vague history; often no external injury
• Subdural hematoma is the most common inflicted intracranial injury
• Maintain high index of suspicion

VP Shunt Patients

• Consider: underlying epilepsy, shunt malfunction, CNS infection
• Shunt-related seizures with fever more likely infectious than mechanical
• Evaluate: shunt series X-ray + head CT for ventricular size; LP/shunt tap if infection suspected

9. Post-Seizure Workup

• Neuroimaging: indicated after status epilepticus or focal/complex seizures
• Lumbar puncture: if CNS infection suspected, or after status epilepticus without clear cause
• EEG: not needed after a first simple febrile seizure; required for refractory/nonconvulsive status (EEG is the only way to diagnose nonconvulsive SE)
• Intubation note: if RSI needed, use agents with antiepileptic activity (propofol, ketamine); prefer short-acting neuromuscular blocker (succinylcholine) to allow ongoing seizure monitoring

• Harriet Lane Handbook, Johns Hopkins, 23rd Ed. - Febrile seizure classification & dosing
• Rosen's Emergency Medicine - Status epilepticus algorithm (American Epilepsy Society 2016)
• Tintinalli's Emergency Medicine, Comprehensive Study - Febrile seizures, epilepsy in children
• Adams and Victor's Principles of Neurology, 12th Ed. - AED choice by seizure type (Table 15-7)
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Pediatric epilepsy syndromes
• Textbook of Family Medicine, 9th Ed. - Status epilepticus, AED dosing table