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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.
Key Questions

What are the unique features of brain


anatomy and physiology and how do they
affect patterns of brain injury?
What is a focused neurologic exam?
What is optimal management of the
brain-injured patient?
How do I diagnose brain death?
Anatomy and physiology effects?

Rigid, nonexpansile skull filled with


brain, CSF, and blood
CBF autoregulation
Autoregulatory compensation
disrupted by brain injury
Mass effect of intracranial hemorrhage
Intracranial Pressure (ICP)

10 mm Hg = Normal
> 20 mm Hg = Abnormal
> 40 mm Hg = Severe
Many Pathologic Processes affect outcome
Sustained ICP lead to brain function and
outcome
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
Classification of Brain injury

By Mechanism
Blunt: High and
low velocity

Penetrating:
GSW and other
Classification of Brain Injury

By Morphology: Skull Fractures

Depressed / nondepressed
Vault
Open / Closed

With / without CSF leak


Basilar With / without cranial
palsy
Classification of Brain Injury

By Morphology: Brain

Epidural (extradural)
Focal Subdural
Intracerebral

Concussion
Diffuse Multiple contusions
Hypoxic / ischemic injury
Diffuse Brain Injury

Mild concussion Severe, ischemic insult


Epidural Hematoma

Associated with skull fracture


Classic: Middle meningeal artery tear
Lenticular / biconvex
Lucid interval
Can be rapidly fatal
Early evacuation essential
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
Contusion / Hematoma

Coup / contracoup injuries


Most common: Frontal / temporal lobes
CT change usually progressive
Most conscious patient: No operation
Mild Brain Injury

GCS Score = 14-15 X-rays as indicated


History Alcohol / drug
Exclude systemic screens as indicated
injuries Liberal use of head
Neurologic exam CT

Observe or discharge based on findings


Moderate Brain Injury

GCS Score = 9-13 Admit and observe


Initial evaluation Frequent
same as for mild neurologic exams
injury Repeat CT scan
CT scan for all 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
Priorities

ABCDE
Minimize secondary brain injury
Administer O2
Maintain blood pressure
(systolic > 90 mm Hg)
Focused Neurologic Exam?

GCS score
Pupils
Lateralizing signs

Consult neurosurgeon early


Medical Management

Intravenous fluids
Euvolemia
Isotonic
Controlled ventilation
Goal: PaCO2 at 35 mm Hg
Indications for CT Scan?

All patient with


suspicion of brain
injury
Medical Management

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

Other medications
Anticonvulsants
Sedation
Paralytics
Surgical Management

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

Intracranial Mass Lesion


May be life-threatening if expanding
rapidly
Immediate neurosurgical consult
Hyperventilation / Mannitol
Damage control craniotomy: Transfer
to neurosurgeon (rural / austere areas)
Diagnose brain death?

Clinical Ancillary Studies


GCS Score = 3 EEG: No activy
Nonreactive pupils Brain scan: No flow
Absent brainstem ICP > Map x 3
reflexes hours
No spontaneous No cardiac response
ventilatory effort to atropine
Remember, organ donation
: 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
: 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