Transcript seventh edition International Trauma Life Support for Emergency Care Providers Head Trauma CHAPTER 10

seventh edition
International Trauma Life Support
for Emergency Care Providers
Head Trauma
CHAPTER 10
Head Trauma
© Edward T. Dickinson, MD
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Overview
• Anatomy of head and brain
• Pathophysiology of traumatic injury
• Primary and secondary injury
– Mechanisms of secondary brain injury
• Assessment, management, potential
problems
• Management of cerebral herniation
syndrome
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Trauma
• Traumatic brain injury (TBI)
– Major cause of death and disability
– CNS injury in 40% multiple trauma
 Death rate twice of non-CNS injury
– 25% of trauma fatalities
• Assume spinal injury with serious injury
– Potential for altered mental status
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Anatomy
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
Primary
– Immediate damage to brain tissue
– Direct result of injury force
– Little can change injury after it occurs
Secondary
– Result of hypoxia or decreased perfusion
– Prehospital care can help prevent
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
Coup
– The “3rd collision”
– Area of original impact
Contracoup
– The “4th collision”
– Rebounding hitting
the opposite side
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Anatomy
Intracranial volume
• Brain
• CSF
• Blood vessel volume
 Dilatation with high pCO2
 Constriction with low pCO2
– Slight effect on volume
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Physiology
•Intracranial pressure (ICP)
– Pressure of brain and contents in skull
•Cerebral perfusion pressure (CPP)
– Pressure required to perfuse brain
•Mean arterial pressure (MAP)
– Pressure maintained in vascular system
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Physiology
•Cerebral perfusion
– CPP = MAP – ICP
 MAP constant + ICP increase = CPP decrease
 MAP decrease + ICP constant = CPP decrease
– Hypotension not tolerated with ICP increase
 MAP decrease + ICP increase = CPP critical
 Systolic pressure 110–120 mmHg minimum needed
to maintain sufficient CPP
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Increasing ICP
Vital Sign
Respiration
Pulse
Blood pressure
Change with Increasing ICP
Increase, decrease, irregular
Decrease
Increase, widening pulse pressure
Cushing's response
• As ICP increases, systolic BP increases
• As systolic BP increases, pulse rate decreases
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
The Injured Brain
•Cerebral herniation syndrome
– Brain forced downward
 CSF flow obstructed, pressure on brainstem
– Level of consciousness
 Decreasing, rapid progression to coma
– Associated symptoms
 Ipsilateral pupil dilatation, out-downward deviation
 Contralateral paralysis or decerebrate posturing
 Respiratory arrest, death
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Herniation Syndrome
•Aggressive therapy needed
– Hyperventilation is indicated

Ventilate 20 per minute for adult

Ventilate 25 per minute for children

Ventilate 30 per minute for infants

Maintain ETCO2 30-35 mmHg
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Injuries
•Facial injuries
– Highly vascular, bleeds briskly
 Possible airway compromise
 Aspiration
 Possible shock
– Management
 Direct pressure
 Airway support
– Suction
– ET Intubation
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
© Pearson
Head Injuries
Scalp wound
• Highly vascular, bleeds briskly
 Shock: child may develop
 Shock: adult another cause
• Management
 No unstable fracture:
direct pressure, dressings
 Unstable fracture: dressings,
avoid direct pressure
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
© Edward T. Dickinson, MD
Head Injuries
•Skull injuries
– Linear nondisplaced
– Depressed
– Compound
•Suspect fracture
– Large contusion or darkened
swelling
•Management
– Dressing, avoid excess pressure
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Concussion
– No structural injury to brain
– Level of consciousness
 Variable period of unconsciousness or confusion
 Followed by return to normal consciousness
– Retrograde short-term amnesia
 May repeat questions over and over
– Associated symptoms
 Dizziness, headache, nausea and/or ringing in ears
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Cerebral contusion
– Bruising of brain tissue
 Swelling may be rapid and severe
– Level of consciousness
 Prolonged unconsciousness,
profound confusion or amnesia
– Associated symptoms
 Focal neurological signs
 May have personality changes
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Diffuse axonal injury
– Diffuse injury
 Generalized edema
 No structural lesion
 Most common injury from
severe blunt head trauma
– Associated symptoms
 Unconscious
 No focal deficits
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Anoxic brain injury
– Small cerebral artery spasms due to anoxia
– No-reflow phenomenon
 Cannot restore perfusion of cortex
after 4–6 minutes of anoxia
 Irreversible damage occurs >4–6 minutes
– Hypothermia seems protective
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Intracranial hemorrhage
– Epidural
 Between skull and dura
– Subdural
 Between dura and arachnoid
– Intracerebral
 Directly into brain tissue
– Subarachnoid
 Between the arachnoid and pia mater
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Intracranial Hemorrhage
•Acute epidural hematoma
– Arterial bleed
 Temporal fracture common
 Onset: minutes to hours
– Level of consciousness
 Initial loss of consciousness
 “Lucid interval” follows
– Associated symptoms
 Ipsilateral dilated fixed pupil, signs of increasing ICP,
unconsciousness, contralateral paralysis, death
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Intracranial Hemorrhage
•Acute subdural hematoma
– Venous bleed
 Onset: hours to days
– Level of consciousness
 Fluctuations
– Associated symptoms
 Headache
 Focal neurologic signs
– High-risk
 Alcoholics, elderly, taking anticoagulants
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Intracranial Hemorrhage
•Intracerebral hemorrhage
– Arterial or venous
 Surgery is often not helpful
– Level of consciousness
 Alterations common
– Associated symptoms
 Varies with region and degree
 Pattern similar to stroke
 Headache and vomiting
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Brain Injuries
•Subarachnoid hemorrhage
– Blood in subarachnoid space
 Intravascular fluid “leaks” into brain
 Fluid “leak” causes more edema
– Associated symptoms




Severe headache
Vomiting
Coma
Cerebral herniation syndrome possible
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Trauma Assessment
•ITLS Primary Survey
– Every trauma patient
initially evaluated in
the same sequence
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Trauma Assessment
ITLS Primary Survey
– Limit patient agitation, straining
 Contributes to elevated ICP
– Airway
 Vomiting common within first hour
 Endotracheal intubation
– Preoxygenation
– Nasotracheal or RSI or sedation facilitated
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Head Trauma Assessment
Rapid Trauma Survey
– Head
 Lacerations
 Depressed or open skull fractures
 Stability of skull
 Signs of basilar skull fracture
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Basilar Skull Fracture
Battle's sign
Photo courtesy of David Effron, MD, FACEP
Raccoon eyes
Photo courtesy of David Effron, MD, FACEP
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Pupils
– 3rd cranial nerve
– Bilateral dilated,
unreactive probable
brain stem injury
– Unilateral dilated,
reactive may be ICP
– Other causes




Hypothermia
Drugs
Anoxia
Ocular trauma
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Extremities
•Decorticate
– Arms flexed
and legs extended
•Decerebrate
– Arms extended
and legs extended
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Glasgow Coma Scale
Suspect severe brain injury < GCS 9
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Vital Signs
– Extremely important
– Obtain & record often
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
The Injured Brain
•Hypotension
– Single instance increases mortality
 Adult (systolic <90 mmHg) 150%
 Child (systolic < age appropriate) worse
•Fluid administration for TBI GCS <9
– Titrate to 110–120 mmHg systolic
with or without penetrating hemorrhage
to maintain CPP
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Secondary Survey & Ongoing Exam
•Secondary Survey
– Do not delay scene time if load-and-go
•Ongoing Exam
– Record
 Level of consciousness
 Pupil size & reaction
 GCS
 Weakness or paralysis
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Management
•Hypoxia
– Perfusion decrease causes cerebral ischemia
– Hyperventilation increases hypoxia
significantly more than it decreases ICP
•Assist ventilation
–
–
–
–
–
High-flow oxygen
One breath every 6–8 seconds
SpO2 >95%
Maintain ETCO2 at 35 mmHg
Endotracheal intubation
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Management
– Spinal Motion Restriction
– Consider sedation if aggitated or combative
– Record baseline observations vital signs
– Continuously monitor
– IV access avoid hypotention
– Hyperventilate if cerebral herniation
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hyperventilation Rates
Age Group
Adult
Children
Infants
Normal Rate
8–10 per minute
15 per minute
20 per minute
Hyperventilation
20 per minute
25 per minute
30 per minute
Capnography
• Maintain ETCO2 30-35 mmHg
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Summary
Knowledge of central nervous system
• Essential for assessment and management
Key actions
• Rapid assessment, airway management,
prevent hypotension, frequent Ongoing Exams
Serious head injury has spinal injury
until proven otherwise
• Altered mental status common
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians