Litigation should be settled as soon as possible. To delay settlement usually works to the disadvantage of the patient. Long periods of observation, repetition of a multitude of tests, and waiting only reinforce the patient’s worries and fears and reduce the motivation to return to work. Neuropsychologic tests may be useful in the group with persistent cognitive difficulty, but the results should be interpreted with caution, as depression and poor motivation will degrade performance.
If the physician arrives at the scene of an accident and finds an unconscious patient, a rapid examination should be made before the patient is moved. First it must be determined whether the patient is breathing and has a clear airway and obtainable pulse and blood pressure, and whether there is hemorrhage from a scalp laceration or injured viscera. Severe head injuries that arrest respiration are soon followed by cessation of cardiac function. Injuries of this magnitude are often fatal; if resuscitative measures do not restore and sustain cardiopulmonary function within 4 to 5 min, the brain is usually irreparably damaged. Bleeding from the scalp can usually be controlled by a pressure bandage unless an artery is divided; then a suture becomes necessary. Resuscitative measures (artificial respiration and cardiac compression) should be continued until they are taken over by ambulance personnel. Oxygen should then be administered.
The likelihood of a cervical fracture–dislocation, which may be associated with any severe head injury, is the reason for taking precautions in immobilizing the neck and in moving the patient. In the awake patient, neck pain calls attention to this complication. It should be recalled that even in the absence of a spinal fracture, the spinal cord may be threatened by the instability resulting from ligamentous injuries (posing the risk of subluxation). In the study of 292 patients with traumatic cervical injuries by Demetriades and colleagues, 31 (11 percent) showed subluxations without fracture and 11 (4 percent) had cord injuries with neither fracture nor subluxation. The combined use of standard cervical spine films and cervical CT scanning detected all cervical injuries. After severe head or neck injury, even without direct impact to the neck, it is advisable under supervision to obtain standard anteroposterior, lateral, and oblique neck films, with additional gentle flexion (20 degrees) and extension (30 degrees) views of the neck and a neck CT scan. If these are normal and there is little or no neck pain, the cervical collar is no longer required. If after these studies, or if they cannot be obtained, or if there is significant persistent pain or other neurologic findings induced by head movement, a cervical MRI is advisable. If there are signs of a myelopathy such as flaccid legs or incontinence, urgent MRI is advisable.
In the hospital, the first step is to clear the airway and ensure adequate ventilation by endotracheal intubation if necessary. A search for other injuries must be made, particularly of the abdomen, chest, spine, and long bones.
Chesnut et al (2012), in analyzing the data from the Traumatic Coma Data Bank, found that sustained early hypotension (systolic blood pressure <90 mm Hg) was associated with a doubling of mortality. If shock was present on admission to the emergency ward, the mortality was 65 percent. Although the hypotension that follows most injuries is a vasodepressor response and usually comes under control within approximately 1 h without pressor drugs, a large, unimpeded intravenous line should be inserted. Persistent hypotension because of head injury alone is an uncommon occurrence and should always raise the suspicion of thoracic or abdominal internal bleeding, extensive fractures, or trauma to the cervical cord, or diabetes insipidus. Initially, the infused fluid should be normal saline, avoiding the administration of excessive “free water” because of its adverse effect on brain edema. Oxygen should continue to be administered until it can be shown that the arterial oxygen saturation is normal.