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Primary survey and immediate threats
Stabilization priorities
If airway compromise or GCS 8 or less, intubation with cervical spine precautions
Etomidate 0.3 mg/kg IV for induction
If hypotension risk, ketamine 1 to 2 mg/kg IV as alternative
Rocuronium 1.2 mg/kg IV for paralysis
If succinylcholine appropriate, 1.5 mg/kg IV
If hypoxia, oxygenation escalation to maintain SpO2 90% or higher
Brain Trauma Foundation severe TBI guidance includes avoiding hypoxia SpO2 under 90% (Level III)
If hypotension, resuscitation to avoid SBP under 90 mmHg
Brain Trauma Foundation severe TBI guidance includes avoiding hypotension SBP under 90 mmHg (Level II)
If active external bleeding, hemorrhage control before imaging
Scalp laceration direct pressure
Hemostatic dressing if persistent bleeding
If seizure activity, immediate anticonvulsant therapy
Lorazepam 0.1 mg/kg IV
Maximum 4 mg per dose
Early escalation and consultation
If depressed skull fracture suspected, neurosurgery consultation
If open depressed fracture, emergent operative planning
If basilar skull fracture signs with neurologic decline, neurosurgery consultation
ICU-level monitoring triggers
Declining GCS
New focal deficit
If polytrauma, trauma team activation
ATLS-based priorities with head injury precautions
Immediate imaging and monitoring targets
Early diagnostics
If suspected skull fracture with neurologic symptoms, non-contrast CT head
If concern for cervical injury, CT cervical spine
If open fracture, contamination concern, antibiotics before CT if no delay to life-saving imaging
Time-to-antibiotics priority similar to open fracture principles
Physiologic targets
Normothermia
Fever associated with worse neurologic outcomes in brain injury populations
Normoglycemia
Avoid marked hyperglycemia
Head of bed 30 degrees if tolerated
Venous outflow optimization
Analgesia without hypotension
Avoid oversedation that masks neurologic decline
Key concepts
Injury pattern framing
Linear skull fracture
Often associated with intracranial hemorrhage risk depending on mechanism and location
Depressed skull fracture
Higher risk of dural tear, infection, seizures
Basilar skull fracture
CSF leak risk
Meningitis risk over time
Cranial nerve injury risk
Vascular injury risk when carotid canal involved
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.