Clinical Pathways
Clinical Pathways
Definitive Airway Not Needed
Definitive Airway Not Needed

Definitive Airway Not Needed

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Action

Perform CT head

Decision

Concern for impending herniation?

Yes

  • Consider:
    • Administering hypertonic saline or mannitol
    • Hyperventilation (temporizing)
    • Elevation of head of bed to 30° (Class II)
    • Reversal of anticoagulation if hemorrhage is present (Class I)
    • Seizure prophylaxis with levetiracetam 1 g IV (Class II)
    • Antibiotics
    • SBP control to 130-180 mm Hg (Class II)
  • Obtain neurosurgery consult
  • Transfer to trauma center or admit

No

  • Consider:
    • Reversal of anticoagulation if hemorrhage is present (Class I)
    • Seizure prophylaxis with levetiracetam 1 g IV (Class II)
    • Antibiotics
    • SBP control to 130-180 mm Hg (Class II)
  • Obtain neurosurgery consult
  • Transfer to trauma center or admit

Background

Imaging

Early neurologic imaging is essential for these patients, as it assists with prognostication and determination of the need for surgical intervention.28^{28} A CT head should be performed for every patient with a GSW to the head or face, regardless of whether it appears that the projectile penetrated the skull, as there can be internal neurologic injury even without skull penetration. (See Figure 4) A three-dimensional CT reconstruction is helpful in identifying the projectile’s path, especially with facial injuries.36^{36} CTA is useful in identifying vascular complications and traumatic aneurysms. Repeat CT scans should be performed to identify any worsening injury; any change in neurologic status should also prompt repeat head imaging. Once brain imaging is obtained, early neurosurgical consultation is critical to evaluate for possible operative management.

Circulation

With regard to circulation, it is well established that hypoperfusion can cause secondary brain injury, and it is widely accepted that hypotension should be immediately addressed in traumatic brain injury patients. However, a 2022 secondary analysis of the EPIC traumatic brain injury study suggests a bimodal influence of systolic blood pressure (SBP). This study found worsening mortality <130 mm Hg and >180 mm Hg, with greater mortality in the 90 to 120 mm Hg range than in the 130 to 180 mm Hg range. Mortality rapidly increased in patients with SBP >180 mm Hg.35^{35} With this in mind, early intervention should be directed at optimizing the patient’s blood pressure, whether too high or too low.

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References
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