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