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CEN and TCRN Head Trauma

Updated: May 23, 2022


Epidural hematoma

a. Middle meningeal artery tear from temporal bone injury.

b. Rapid onset – classic S/S - unresponsive, lucid period, second unresponsiveness.

c. Uncal herniation – ipsilateral pupil dilation, contralateral hemiparesis.

d. Burr holes for emergency treatment since blood above the dura; not appropriate for subdural.


Subdural hematoma

a. Tear of the venous bridging veins.

b. Slower decompensation of mental status; hours to weeks.

c. More often in elderly (anticoagulants) and alcoholics from frequent falls.

d. Shaken impact syndrome – triad of SDH, retinal hemorrhage, and posterior rib fractures.


Management of increased intracranial pressure (ICP)

a. Hypertonic saline if hemodynamically unstable.

b. Mannitol (osmotic diuretic) 1 gm/kg bolus if hemodynamically stable. Reduces ICP within 1-5 minutes, peaks at 20-60 minutes. Monitor for pulmonary edema initially.

c. Keep SBP > 100 mmHg (110 if older), no permissive hypotension in head injury.

d. Keep CO2 at 35-37, avoid hypoxemia.

e. Elevate HOB to 30-45 degrees, neutral alignment, remove cervical collar.

f. Quiet and dark environment, limit visitors, speak softly, treat anxiety and pain (Fentanyl decreases ICP), no music, treat fever aggressively.


Head Trauma Resources

· Emergency Nurses Association. Trauma Nursing Core Curriculum, 8th ed., 2019.

· Kent, Kendra. Trauma Certified Registered Nurse Examination Review. Springer, 2017.



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