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Approach to the Critical Patient
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
If warfarin or DOAC use, lower threshold CT head and observation
Suspected open skull fracture
If visible bone or deep wound with bony step-off, urgent neurosurgery and IV antibiotics
C-spine risk
If midline tenderness or neurologic symptoms, immobilization and imaging pathway
Hemorrhage and pain control
Early control plan
Local anesthesia with epinephrine for hemostasis if no contraindication
Lidocaine 1% with epinephrine 1:100,000
Maximum lidocaine dose 7 mg/kg
If large area, consider buffered solution to reduce pain
Systemic analgesia options
Acetaminophen 1,000 mg PO once
Ibuprofen 400 mg PO once if no bleeding risk
If severe pain, fentanyl 25-50 micrograms IV, titrate every 5 minutes to effect
Documentation anchors
Key data for safety
Time of injury
Last normal neurologic status
Mechanism and energy
Loss of consciousness
Anticoagulant or antiplatelet use
Tetanus immunization status
Wound length and depth
Galea involvement
Hemostasis method used
History
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
Known bleeding disorder
Wound-specific history
Laceration details
Foreign body sensation
Persistent pulsatile bleeding
Prior closure attempts
Allergy history for anesthetics or antibiotics
Infection prevention history
Immunization and bite risk
Tetanus vaccination status
Human bite exposure
Animal bite exposure
Immunocompromised status
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Systemic steroids
Physical Exam
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
Skull and facial injury signs
Fracture indicators
Palpable step-off
Crepitus
Scalp hematoma
Battle sign
Raccoon eyes
Hemotympanum
CSF otorrhea or rhinorrhea
Neurologic exam
Neuro screening
Pupillary size and reactivity
Extraocular movements
Speech and language
Motor strength all extremities
Sensation all extremities
Gait if safe
Neck exam
Cervical spine risk
Midline tenderness
Range of motion limitation
Neurologic symptoms in arms or legs
PITFALLS
Common misses
Occult skull fracture under a small scalp laceration
Galea laceration not repaired leading to dehiscence
Retained foreign body after glass injury
Underestimation of blood loss from scalp arterial bleeding
Differential Diagnosis
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
Epileptic seizure (G40.909)
Laboratory Tests
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
Diagnostic Tests
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
MRI limitations
Limited availability for time-sensitive trauma decisions
Not first-line for acute intracranial hemorrhage screening in ED flow
CT
CT head non-contrast
Indications
Decision rule positive features
Anticoagulation with head trauma and concerning symptoms
Palpable skull step-off or deep laceration with bony exposure
Performance and scope
High sensitivity for clinically significant acute hemorrhage in appropriate time window
Detects skull fractures and intracranial air
Guideline alignment
ACEP adult mild TBI imaging guidance supports decision-rule use for CT selection (ACEP Level B)
Avoid CT in clearly low-risk patients by validated decision tools (ACEP Level B)
CT cervical spine
Indications
Midline tenderness
Neurologic deficit
High-risk mechanism
Inability to clinically clear due to intoxication or distracting injury
Ultrasound
POCUS applications
Soft tissue foreign body detection
Radiolucent material suspicion
Dynamic scanning along wound track
Skull fracture screening in pediatrics as adjunct
Cortical disruption at site of hematoma or laceration
Not a replacement for CT when intracranial injury risk is significant
Hematoma characterization
Subgaleal fluid collection extent
Guidance for drainage only in selected cases
Disposition
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
Treatment
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
Special Populations
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
Pediatric head injury rules alignment where available
Ultrasound adjunct for skull fracture at scalp hematoma site
Closure and comfort
LET gel for analgesia
Child-life support and immobilization safety
Subgaleal hemorrhage risk in infants
Tachycardia or pallor with scalp swelling
Lower threshold for CBC and observation
Background
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
Staples often preferred on scalp
Fast application
Effective hemostasis
Imaging guided by validated rules
Reduces missed intracranial injury while avoiding unnecessary CT (ACEP Level B)
Patient Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.