Management of Head Trauma from Falls: Precautions and CT Scan Indications

Initial Assessment and Precautions

The American College of Surgeons recommends assessing the Glasgow Coma Scale (GCS) score, pupillary size, and reactivity, which are key predictors of neurological outcome at 6 months 1, 2
Documenting each component of GCS (Eye-Verbal-Motor) separately is crucial, with particular attention to motor response, which remains robust even in sedated patients 2
Repeated neurological examinations should be performed to detect secondary deterioration, with the frequency of checks depending on the severity of the TBI: every 30 minutes for the first 2 hours, then hourly for 4-12 hours for moderate TBI (GCS 9-13) 1, 2, 3
Maintaining systolic blood pressure >110 mmHg is essential to prevent secondary cerebral insults 5
Preventing and promptly correcting hypoxemia (SaO₂ <90%) is critical, as it significantly worsens neurological outcomes 3

The Brain Trauma Foundation recommends investigating and correcting other systemic factors that may cause secondary cerebral insults, such as hypotension, hypoxemia, and coagulopathy 1, 3
The combination of hypotension and hypoxemia is particularly dangerous, with a 75% mortality rate 3

Severe TBI patients should be managed by a pre-hospital medical team and transferred as soon as possible to specialized centers with neurosurgical facilities, as management in a specialized neuro-intensive care unit is associated with improved outcomes 5

The American College of Emergency Physicians recommends immediate brain and cervical CT scan for severe TBI (GCS ≤8) and systematic and prompt brain and cervical CT scan for moderate TBI (GCS 9-13) 5, 6
For mild TBI (GCS 14-15) with risk factors, such as loss of consciousness, posttraumatic amnesia, headache, vomiting, age >60 years, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicle, posttraumatic seizure, GCS <15, focal neurological deficit, or coagulopathy, a CT scan is indicated 3, 4, 6

Less than 1% of mild TBI patients will have lesions requiring neurosurgical intervention, but 5-15% may have compromised function 1 year after injury 4, 7
Implementation of protocols focused on monitoring and prevention of secondary insults significantly reduces mortality, with a strength of evidence level of high 3