Committee on Trauma Presents

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Head Trauma

Objectives

➢ Describe basic intracranial physiology. ➢ Recognize the importance of limiting

secondary brain injury. ➢ Perform a focused neurologic exam. ➢ Stabilize and arrange for definitive care.

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➢ Rigid, nonexpansile skull filled with brain, CSF, and blood

➢ CBF autoregulation ➢ Autoregulatory compensation

disrupted by brain injury ➢ Mass effect of intracranial hemorrhage

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Anatomy and physiology effects?

Monro-Kellie Doctrine

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Ven. Vol.

Art. Vol. Brain CSFMass

Arterial Volume Brain CSF75 mL Mass

75 mL

Venous Volume

Art. Vol.

Brain CSF

Volume – Pressure Curve

©ACSVolume of Mass

60- 55- 50- 45- 40- 35- 30- 25- 20- 15- 10- 5-

ICP (mm Hg)

Compensation

Herniation

Point of Decompensation

Intracranial Pressure (ICP)

➢ 10 mm Hg = Normal ➢ > 20 mm Hg = Abnormal ➢ > 40 mm Hg = Severe ➢ Many pathologic processes affect outcome ➢ Sustained ↑ ICP leads to ↓ brain function and

outcome

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Cerebral Perfusion Pressure*

©ACS* CPP ≠ Cerebral Blood Flow

MBP ICP CPP

Normal

Cushing’s Response

Hypotension

– =

30

90

100

50

10 80

20

20

80

Autoregulation

➢ If autoregulation is intact, CBF is maintained with a mean BP of 50 to 160 mm Hg.

➢ Moderate or severe brain injury: Autoregulation often impaired

➢ Brain more vulnerable to episodes of hypotension → secondary brain injury

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Mild Brain Injury

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➢ GCS Score = 14–15 ➢ History ➢ Exclude systemic

injuries ➢ Neurologic exam

➢ X-rays as indicated ➢ Alcohol / drug

screens as indicated ➢ Liberal use of head

CT

Observe or discharge based on findings

Moderate Brain Injury

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➢ GCS Score = 9–13 ➢ Initial evaluation

same as for mild injury

➢ CT scan for all

➢ Admit and observe • Frequent neurologic exams • Repeat CT scan

➢ Deterioration: Manage as severe head injury

Severe Brain Injury

➢ GCS Score = 3–8 ➢ Evaluate and resuscitate ➢ Intubate for airway protection ➢ Focused neurologic exam ➢ Frequent reevaluation ➢ Identify associated injuries

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Classifications of Brain Injury

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By Morphology: Brain

Focal

Diffuse

• Epidural (extradural) • Subdural • Intracerebral

• Concussion • Multiple contusions • Hypoxic / ischemic injury

Diffuse Brain Injury

➢ Mild concussion → Severe, ischemic insult

©ACSNormal CT Diffuse Injury

Contusion / Hematoma

➢ Coup / contracoup injuries ➢ Most common: Frontal / temporal lobes ➢ CT changes usually progressive ➢ Most conscious patients: No operation

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Contusion / Hematoma

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Large frontal contusion with

shift

Epidural Hematoma

➢ Associated with skull fracture ➢ Classic: Middle meningeal artery tear ➢ Lenticular / biconvex ➢ Lucid interval ➢ Can be rapidly fatal ➢ Early evacuation essential

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Epidural Hematoma

Uncal herniation

Temporal Epidural

Hematoma

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Subdural Hematoma

➢ Venous tear / brain laceration ➢ Covers cerebral surface ➢ Morbidity / mortality due to underlying

brain injury ➢ Rapid surgical evacuation

recommended, especially if > 5 mm shift of midline

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Subdural Hematoma

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Priorities

➢ ABCDE

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➢ Minimize secondary brain injury• Administer O2 • Maintain blood pressure

(systolic > 90 mm Hg)

Focused Neurologic Exam?

➢ GCS Score

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Consult neurosurgeon early

➢ Pupils➢ Lateralizing signs

Indications for CT Scan?

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All patients with suspicion of brain

injury

Medical Management

➢ Controlled ventilation

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➢ Intravenous fluids• Euvolemia • Isotonic

• Goal: Paco2 at 35 mm Hg

Medical Management

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➢ Mannitol• Use with signs of tentorial herniation • Dose: 1.0 g / kg IV bolus • Consult with neurosurgeon first

Medical Management

➢ Other medications

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• Anticonvulsants • Sedation • Paralytics

Surgical Management

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Scalp Injuries➢ Possible site of major blood loss ➢ Direct pressure to control bleeding ➢ Occasional temporary closure

Surgical Management

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Intracranial Mass Lesion➢ May be life-threatening if expanding

rapidly ➢ Immediate neurosurgical consult ➢ Hyperventilation / Mannitol ➢ Damage control craniotomy: Transfer

to neurosurgeon (rural / austere areas)

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?

Summary: What should I do?

➢ Maintain mean BP > 90 mm Hg ➢ Maintain Paco2 near / at 35 mm Hg ➢ Use isotonic solution for euvolemia ➢ Frequent neurologic exams ➢ Liberal use of CT scans ➢ Early neurosurgical consult

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Summary: What should I not do?

➢ Allow patient to become hypotensive ➢ Over-aggressively hyperventilate ➢ Use hypotonic IV fluids ➢ Use long-acting paralytics ➢ Paralyze before performing complete exam ➢ Depend on clinical exam alone

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