01Approach to the Critical Patient/attcp50

Immediate priorities

›Initial stabilization

›Airway compromise from facial bleeding or decreased consciousness

›If GCS < 13, resuscitation bay

›If vomiting or aspiration risk, airway protection strategy

›Breathing and oxygenation

›SpO2 target 94-98%

›If hypoventilation or apnea, bag-mask ventilation

›Circulation and hemorrhage control

›Direct pressure with bulky dressing

›If persistent bleeding, hemostatic clamp to focal vessel

›If brisk arterial bleeding, running locked hemostatic suture or vessel ligation

›If large blood loss concern, two large-bore IVs

›Neurologic risk stratification

›GCS

›Seizure activity

›Focal neurologic deficit

›Signs of basilar skull fracture

›Temperature and exposure

›Full head and neck exposure

›Warm blankets if pediatric or hypothermia risk

Red flags and escalation triggers

›High-risk trauma features

›Altered mental status or amnesia

›If worsening mental status, immediate CT head

›Repeated vomiting

›If persistent vomiting, CT head pathway

›Anticoagulation or bleeding diathesis

02History/hx39

Injury context

›Mechanism and timing

›Blunt trauma vs sharp injury

›High-energy mechanism

›Assault or weapon

›Time since injury

›Delayed presentation > 12 hours

›Environment and contamination

›Soil or farm exposure

›Glass or metal exposure

Head injury features

›Intracranial risk symptoms

›Loss of consciousness

›Amnesia

›Headache severity

›Vomiting episodes count

›Seizure

›Confusion or behavior change

›Intoxication

Bleeding and medication history

›Hemorrhage risk

›Warfarin use

›Last INR if known

›DOAC use

›Last dose timing

›Antiplatelet therapy

›Aspirin

›Clopidogrel

03Physical Exam/exam50

Primary survey focused exam

›Initial observations

›Hemodynamic status

›Tachycardia out of proportion to pain

›Hypotension suggesting hemorrhage or polytrauma

›Mental status

›GCS components

›Orientation

Scalp and wound assessment

›Wound characteristics

›Location by region

›Frontal

›Temporal

›Parietal

›Occipital

›Length and depth

›Superficial dermal

›Subcutaneous

›Galea aponeurotica violation

›Active bleeding pattern

›Venous oozing

›Arterial spurting

›Tissue status

›Devitalized edges

›Flap or avulsion

›Foreign material

›Glass fragments

›Dirt or gravel

04Differential Diagnosis/ddx26

Traumatic conditions to exclude

›Intracranial injury

›Concussion (S06.0X0A)

›Traumatic intracranial hemorrhage (S06.36XA)

›Epidural hematoma (S06.4X0A)

›Subdural hematoma (S06.5X0A)

›Subarachnoid hemorrhage (S06.6X0A)

›Skull fracture

›Closed skull fracture (S02.0XXA)

›Open skull fracture (S02.91XB)

›Basilar skull fracture (S02.10XA)

›Cervical spine injury

›Cervical vertebral fracture (S12.9XXA)

›Cervical spinal cord injury (S14.109A)

Wound-related conditions

›Soft tissue complications

›Scalp avulsion (S08.0XXA)

›Scalp hematoma

›Wound infection (L08.9)

›Necrotizing soft tissue infection (M72.6) in severe contamination or immunocompromise

›Foreign body

›Retained foreign body in soft tissue (M79.5)

Mimics and alternate etiologies

›Syncope-related fall

›Vasovagal syncope (R55)

›Cardiac arrhythmia (I49.9)

›Hypoglycemia (E16.2)

›Seizure-related fall

05Laboratory Tests/lt21

Hemorrhage and anticoagulation evaluation

›Bleeding risk labs

›Complete blood count for anemia or thrombocytopenia

›Hemoglobin trend if ongoing bleeding

›Platelet count for antiplatelet exposure or hematologic disease

›INR for warfarin exposure

›If INR supratherapeutic with head trauma, admission or prolonged observation pathway

›aPTT for heparin exposure

›If prolonged with trauma, bleeding risk escalation

Metabolic contributors and co-ingestions

›Point-of-care and targeted labs

›Capillary glucose for syncope, seizure, altered mental status

›If < 3.9 mmol/l, immediate correction

›Ethanol level for altered mental status where it changes imaging threshold

›Clinical sobriety not reliable in head injury risk stratification

Transfusion planning

›If significant bleeding or large wound

›Type and screen

›If hemodynamic instability, type and crossmatch

›Venous blood gas if shock concern

›Lactate for hypoperfusion

Infection-related tests

›If open skull fracture or deep contamination

›Blood cultures only if systemic infection concern

›Fever or hemodynamic instability

06Diagnostic Tests/dt56

Scoring Systems

›Clinical decision tools for imaging

›Canadian CT Head Rule for adults with minor head injury

›High-risk criteria

›GCS < 15 at 2 hours after injury

›Suspected open or depressed skull fracture

›Signs of basilar skull fracture

›Vomiting 2 or more episodes

›Age 65 years or older

›Medium-risk criteria

›Amnesia before impact 30 minutes or more

›Dangerous mechanism

›New Orleans Criteria for minor head injury with GCS 15

›Headache

›Vomiting

›Age > 60 years

›Drug or alcohol intoxication

›Persistent anterograde amnesia

›Visible trauma above the clavicles

›Seizure

›Cervical spine clinical rules

›Canadian C-spine Rule triggers imaging

›NEXUS criteria for low-risk clearance

MRI

›MRI indications

›Persistent neurologic symptoms with normal CT

›Diffuse axonal injury suspicion

›Suspected cervical ligamentous injury with negative CT and ongoing pain

07Disposition/dispo25

Discharge criteria

›Safe discharge after repair

›Hemostasis achieved with stable dressing

›Normal neurologic exam and low-risk head injury profile

›No concerning decision-rule features for CT, or negative CT with stable exam

›Reliable supervision and return precautions

›Tetanus updated as indicated

Observation or admission criteria

›Observation indications

›Concussion symptoms with high-risk social situation

›Anticoagulation with head trauma and uncertain symptom evolution

›Intoxication preventing reliable neuro assessment

›Admission indications

›Intracranial hemorrhage on imaging

›Open or depressed skull fracture

›Persistent altered mental status

›Uncontrolled bleeding or large transfusion requirement

Consultation and transfer

›Specialty involvement triggers

›Neurosurgery

›Open, depressed, or basilar skull fracture suspicion

›Intracranial hemorrhage

›CSF leak

›Plastic surgery

›Large avulsion

›Significant tissue loss requiring flap

›ENT or maxillofacial

›Associated facial fractures or complex ear lacerations

08Treatment/t84

Hemostasis and wound preparation

›Bleeding control steps

›Direct pressure and elevation

›Continuous pressure 10-15 minutes before reassessment

›Local vasoconstriction

›Lidocaine with epinephrine infiltration

›Lidocaine 1% with epinephrine 1:100,000

›Maximum lidocaine dose 7 mg/kg

›If cardiovascular disease, use minimal effective volume

›Mechanical control

›Hemostatic forceps to bleeding vessel

›If focal arterial bleed, suture ligation with absorbable suture

›Temporary scalp clips for diffuse bleeding

›Remove after definitive closure

›Cleansing and irrigation

›Irrigation strategy

›Normal saline irrigation

›High-pressure irrigation for contaminated wounds

›Typical volume 500-1,000 ml depending on contamination

›Hair management

›Parting hair for visualization

›Avoid shaving if possible due to infection risk

Anesthesia options

›Topical anesthesia

›LET gel for pediatric or needle-avoidant patients

›Lidocaine 4% + epinephrine 0.1% + tetracaine 0.5%

›Onset 20-30 minutes

›Avoid in heavily contaminated wounds where delay increases bleeding risk

›Local infiltration

›Lidocaine 1%

›Maximum dose 4.5 mg/kg

›Lidocaine 1% with epinephrine 1:100,000

›Maximum dose 7 mg/kg

›Regional blocks

›Scalp nerve blocks for large wounds

›Supraorbital

›Supratrochlear

›Auriculotemporal

›Greater occipital

›Lesser occipital

Closure techniques

›Primary closure selection

›Staples

›Fast closure for linear scalp lacerations

›Good hemostasis in highly vascular scalp

›Sutures

›If irregular edges or tension areas

›3-0 or 4-0 nylon for skin

›Hair apposition technique

›For straight lacerations under low tension

›Avoid if heavy bleeding or poor hair length

›Deep layer repair

›Galea repair indications

›Galea laceration 0.5 cm or more

›Tension reduction and dead space control

›Galea repair material

›3-0 or 4-0 absorbable suture

›Simple interrupted pattern

›Dressing strategy

›Pressure dressing after closure if hematoma risk

›Recheck after 15-30 minutes for rebleeding

Antibiotics

›Prophylaxis decision framework

›Routine prophylaxis not indicated for clean scalp lacerations

›Low infection rates due to high vascularity

›Consider prophylaxis for high-risk wounds

›Gross contamination

›Crush injury

›Delayed closure with high bioburden

›Human or animal bite

›Immunocompromised state

›Suggested oral regimens when indicated

›Cephalexin 500 mg PO every 6 hours for 3-5 days

›If penicillin allergy, clindamycin 300 mg PO every 6-8 hours

›Bite wound coverage

›Amoxicillin-clavulanate 875/125 mg PO every 12 hours for 3-5 days

Tetanus prophylaxis

›Tetanus update rules

›Clean minor wound

›If last tetanus 10 years or more, Td or Tdap

›Dirty or high-risk wound

›If last tetanus 5 years or more, Td or Tdap

›If unknown or incomplete vaccination, add tetanus immune globulin

Imaging and head injury management

›Mild TBI pathway integration

›If decision rule positive, CT head

›ACEP Level B support for validated decision rules

›If CT negative but symptoms persist

›Observation and serial neuro checks

›Concussion counseling and graded return guidance

09Special Populations/sp33

Pregnancy

›Pregnancy-specific considerations

›Maternal stabilization priority

›Oxygenation and perfusion targets for placental support

›Left lateral tilt if hypotensive and viable gestation

›Imaging principles

›CT head when clinically indicated

›Shared decision-making for borderline indications

›Medication considerations

›Acetaminophen preferred analgesic

›Avoid NSAIDs especially later gestation when alternatives exist

Geriatric

›Older adult considerations

›Higher intracranial hemorrhage risk after minor trauma

›Lower threshold for CT head

›Lower threshold for observation if living alone

›Anticoagulant and antiplatelet prevalence

›INR testing if warfarin exposure

›Extended observation if neurologic assessment reliability limited

›Skin fragility and wound healing

›Gentle edge handling

›Deeper layer closure to reduce tension

Pediatrics

›Pediatric considerations

›Non-accidental trauma screening

›Inconsistent history

›Multiple bruises or injuries in different stages

›Imaging decisions

10Background/b30

Epidemiology

›Frequency and risk context

›Scalp lacerations common in blunt head trauma

›High vascularity leads to dramatic bleeding

›Infection risk generally low in clean scalp wounds

›Increased risk with contamination or bite exposure

›Co-injury risk depends on mechanism

›High-energy trauma increases skull fracture and intracranial injury probability

Pathophysiology

›Anatomic features driving presentation

›Scalp layers

›Skin

›Connective tissue with vessels

›Galea aponeurotica

›Loose areolar tissue

›Pericranium

›Bleeding mechanism

›Dense connective tissue holds vessels open

›Limited vasospasm leads to persistent bleeding

›Subgaleal space

›Potential space for significant blood accumulation

Therapeutic Considerations

›Rationale for key interventions

›Early hemostasis reduces hypovolemia and improves visualization

›Epinephrine-containing anesthetic improves field and decreases bleeding

›Galea repair prevents complications

›Reduces tension on skin closure

›Reduces dead space and hematoma risk

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Wound care and follow-up

›Keep dressing in place for 12-24 hours

›Gentle cleansing with soap and water after 24 hours

›Avoid soaking or swimming until healed

›Pressure dressing replacement if oozing

›Suture or staple care

›Staples removal 7-10 days

›Sutures removal 7-10 days if used for scalp skin

›Hair apposition glue naturally detaches in 7-10 days

›Pain control guidance

›Acetaminophen as first-line

›Avoid NSAIDs for 24 hours if significant bruising or bleeding concern

›Return to ED immediately for head injury red flags

›Worsening headache

›Repeated vomiting

›Confusion or unusual behavior

›New weakness, numbness, trouble speaking, or trouble walking

›Seizure

›Increasing drowsiness or cannot be awakened normally

›Clear fluid from nose or ear

›Severe neck pain

›Return to ED for wound red flags

›Bleeding that does not stop with 10 minutes of direct pressure

›Increasing redness, swelling, warmth, or pus

›Fever

›Wound opening or expanding swelling

12References/r17

Guidelines and decision tools

›Clinical guidance sources

›ACEP clinical policy on adult mild traumatic brain injury and imaging (ACEP Level B statements)

›Decision-rule supported CT selection

›Avoid CT in clearly low-risk by validated rules

›Canadian CT Head Rule derivation and validation studies

›High-risk and medium-risk criteria structure

›New Orleans Criteria for minor head injury study

›GCS 15 symptom-based triggers

›CDC tetanus wound management guidance

›Vaccine timing by wound type

›Tetanus immune globulin indications

Procedural and wound care sources

›Laceration repair references

›Emergency wound management texts for scalp closure methods

›Staple vs suture selection

›Galea repair indications

›Foreign body evaluation references

›Ultrasound utility for radiolucent foreign bodies

Evidence & Review

Evidence & Review