Head Injury Guidelines

Updated: Oct 01, 2018
  • Author: David A Olson, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Guidelines Summary

Guidelines for traumatic brain injury are undergoing constant revision with the incorporation of newly completed clinical studies and research.

The American Association of Neurological Surgeons generally does not produce specific treatment guidelines. However, the Brain Trauma Foundation recently published revised guidelines for severe traumatic brain injury, and their recommendations have been endorsed by neurosurgical professional organizations. These guidelines are based on high-to-moderate quality evidence and are summarized below: [167]

1.  If decompressive craniectomy is performed, a large frontal, temporal, and parietal one is preferred over smaller craniectomies.

2.  There is no evidence that hypothermia improves outcomes.

3.  There is insufficient evidence to support a specific hyperosmolar treatment (mannitol or hypertonic saline) for increased intracranial pressure.

4.  There is insufficient evidence to support CSF drainage.

5.  There is insufficient evidence to support prophylactic hyperventilation.

6.  There is insufficient evidence for sedatives, analgesics, or anesthetic agents.

7.  Steroids are to be avoided as they increase mortality.

8.  Enteral feeding should be initiated within the first week.

9.  Early tracheostomy placement is recommended.

10.  Povidone-iodine oral care should not be used as this may increase ARDS.

11.  There is insufficient evidence to support specific DVT-prevention strategies.

In 2013, the American Academy of Neurology [168] introduced guidelines for concussion in sports. These guidelines endorsed symptom checklists to be used by non-physician assesors to help diagnose concussions. An athlete with an identified concussion is prohibited from returning to play until the signs and symptoms of the concussion have resolved. Athletes with multiple concussions and objective neurologic or cognitive impairments are retired from play.

In 2008, the CDC recommended imaging guidelines for mild traumatic brain injury, which were re-affirmed in 2013.  A CT of the head is indicated in patients with head injury and loss of consciousness or amnesia if the patient has also had any of the following: headache, vomiting, age greater than 60 years, drug or alcohol intoxication, short-term memory loss, evidence of trauma above the clavicles, a seizure, a focal neurologic deficit, a GCS less than 15, or a coagulopathy. Such complicated decisions rules seem impractical and will hopefully be clarified with further research. [169]