Committee on Trauma Presents

Head Trauma

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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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Anatomy and physiology effects?



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

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CBF autoregulation



Autoregulatory compensation disrupted by brain injury

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Mass effect of intracranial hemorrhage

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Monro-Kellie Doctrine Venous Volume Art.

Vol.

Brain CSF 75 mL Ven.

Vol.

Art.

Vol.

Brain Mass CSF Arterial Volume Brain Mass CSF 75 mL

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Volume – Pressure Curve

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

ICP

(mm Hg)

Point of Decompensation Compensation Volume of Mass Herniation

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Intracranial Pressure (ICP)

  

10 mm Hg > 20 mm Hg > 40 mm Hg = = = Normal Abnormal Severe



Many pathologic processes affect outcome



Sustained



ICP leads to



outcome brain function and

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Cerebral Perfusion Pressure* Normal Cushing’s Response Hypotension MBP – ICP = CPP 90 10 80 100 50 20 20 80 30 * CPP



Cerebral Blood Flow

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Autoregulation

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

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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



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

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Moderate Brain Injury



GCS Score = 9–13

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Initial evaluation same as for mild injury



Admit and observe



Frequent neurologic exams



Repeat CT scan



CT scan for all

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Deterioration: Manage as severe head injury

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Severe Brain Injury



GCS Score = 3–8

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Evaluate and resuscitate

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Intubate for airway protection



Focused neurologic exam

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Frequent reevaluation



Identify associated injuries

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Classifications of Brain Injury By Morphology: Brain Focal



Epidural (extradural)



Subdural



Intracerebral Diffuse



Concussion



Multiple contusions



Hypoxic / ischemic injury

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Diffuse Brain Injury



Mild concussion



Severe, ischemic insult Normal CT Diffuse Injury

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Contusion / Hematoma

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Coup / contracoup injuries

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Most common: Frontal / temporal lobes

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CT changes usually progressive

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Most conscious patients: No operation

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Contusion / Hematoma Large frontal contusion with shift

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Epidural Hematoma

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Associated with skull fracture

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Classic: Middle meningeal artery tear

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Lenticular / biconvex

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Lucid interval

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Can be rapidly fatal

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Early evacuation essential

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Epidural Hematoma Temporal Epidural Hematoma Uncal herniation

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Subdural Hematoma



Venous tear / brain laceration

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Covers cerebral surface



Morbidity / mortality due to underlying brain injury

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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 O 2 Maintain blood pressure (systolic > 90 mm Hg)

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Focused Neurologic Exam?



GCS Score

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Pupils



Lateralizing signs Consult neurosurgeon early

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Indications for CT Scan?

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Medical Management

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Intravenous fluids



Euvolemia



Isotonic

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Controlled ventilation



Goal: Paco 2 at 35 mm Hg

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Medical Management

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Mannitol



Use with signs of tentorial herniation

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Dose: 1.0 g / kg IV bolus

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Consult with neurosurgeon first

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Medical Management

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Other medications



Anticonvulsants

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Sedation



Paralytics

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Surgical Management Scalp Injuries

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Possible site of major blood loss

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Direct pressure to control bleeding

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Occasional temporary closure

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Surgical Management Intracranial Mass Lesion

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May be life-threatening if expanding rapidly

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Immediate neurosurgical consult

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Hyperventilation / Mannitol

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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 Paco 2 near / at 35 mm Hg



Use isotonic solution for euvolemia



Frequent neurologic exams

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Liberal use of CT scans

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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

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Paralyze before performing complete exam



Depend on clinical exam alone

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