HEAD TRAUMA

FOR
GENERAL PRACTITIONERS

HAPPY FRIDAY KNIGHT

 OUTLINES

• Anatomy review
• Physiology review
• Classifications of head injuries
• Investigation: CT brain
• Treatment guidelines
 INTRODUCTION

• Primary goal treatment is to prevent secondary brain insult

• CT brain should not delay patient transfer to a trauma
center
 ANATOMY REVIEW

• Scalp
• Skull
• Meninges
• Brain
• Ventricular system
 SCALP

galea

Subgaleal
connective
tissue

https://teachmeanatomy.info/head/areas/scalp/
 SKULL AND MENINGES

American college of surgeons committee on trauma. ATLS student course manual. 10th ed. Chicago: American
college of surgeons, 2018.
 BRAIN AND VENTRICULAR SYSTEM

American college of surgeons committee on trauma. ATLS student course manual. 10th ed. Chicago: American
college of surgeons, 2018.
https://www.sciencedirect.com/topics/neuroscience/ventricular-system
Reilly P. Management of intracranial pressure and cerebral perfusion. Head injury. London,
1997.
 PHYSIOLOGY REVIEW:
MONROE-KELLIE DOCTRINE

• Vother: volume of any abnormal component  hematoma, tumor

• Cranium is
• Nonexpandable
• incompressible
 CEREBRAL BLOOD FLOW

• CPP = MAP - ICP

• Pressure autoregulation: MAP 50-150 mmHg is
autoregulated to maintain constant CBF
 CLASSIFICATION OF HEAD INJURIES

• Severity
• Morphology
• Intracranial lesion
 HOW TO READ CT BRAIN

• ABCDEF
• A – airspaces: pneumocephalus, trauma or sinus
• B – blood, bone, brain
• C – CSF
• D – Dura
• E – eyes
• F - face
Anzai Y et al. Imaging of
traumatic brain injury. New
York: WL, 2015.
 EPIDURAL HEMATOMA

• Lens shape
• Hyperdensity
• Lucid interval
• Injury to middle meningeal
a.
• Coup lesion

Anzai Y et al. Imaging of traumatic brain injury. New

York: WL, 2015.
 SUBDURAL HEMATOMA

• Tear bridging vein • Acute

• < 1day
• Countercoup lesion • hyperdensity
• Crescent shape • Subacute
• 1-3 days
• Isodense
• Chronic
• Hypodense with septation
 SUBARACHNOID HEMORRHAGE

• Traumatic: Serpentine
hyperdense lesion along
sulci
• Aneurysmal: maximum
thickness at basal cistern
INTRAVENTRICULAR HEMORRHAGE
 CEREBRAL CONTUSION

• Fluffy appearance
• Mixed hypo-hyperdense,
inhomogenous
• Ill-defined border
• Adjacent to bony prominence
 INTRACEREBRAL HEMORRHAGE

• Well-defined borde
• More homogenous
 CEREBRAL CONCUSSION

• GCS = 15
• No neurodeficit after recovery
 DIFFUSE AXONAL INJURY

• Unconscious > 24 hr
• Spot hemorrhage
along grey-white
matter junction
 CEREBRAL EDEMA

• Midline shift
• Slit ventricle
• Herniation
• Loss of sulci
• Loss of grey-white junction
 TREATMENT

• According to severity
• Mild head injury: low, moderate, high risk
• Moderate to severe head injury
• ABCDEs
• Resuscitation and protect airway in severe head injury
• CT brain with C-spine
 MILD TBI: LOW RISK

• GCS 15
• Asymptomatic Discharge with instruction
• No headache
MODERATE TO HIGH RISK
MILD TBI

• Moderate risk
• CT brain and observe 6 h
• admit
• High risk
• CT brain + admit
 MEDICATIONS: MANNITOL

• Indication: signs of herniation, ICP > 22 mmHg

• 20% mannitol 0.25 – 1 g/kg IV in 15 min, then 100 mg IV
q8h
 MEDICATION: DILANTIN

• Early posttraumatic seizure prophylaxis

• 7 days to 2 years if seizure presents
• 15 – 20 mg/kg IV in 30 min, then 100 mg q8h x 7 days
 MEDICATION: DILANTIN

• Indications:
• Immediate posttraumatic seizure or history of seizure
• Posttraumatic amnesia > 30 min
• GCS ≤ 10
• Linear or depressed skull fracture
• Penetrating head injury
• Hemorrahge: EDH, SDH, SAH, ICH, IVH, contusion
• Chronic alcoholism
 TIME TO SURGERY

• EDH
• 30 cm3
• Thickness > 15 mm
• Midline shift > 5 mm
 TIME TO SURGERY

• SDH
• > 10 mm thick
• > 5 mm midline shift
• GCS drop > 2
• Asymmetric pupil
• ICP > 20 mmHg
 TIME TO SURGERY

• SAH
• When hydrocephalus presents
 TIME TO SURGERY

• ICH
• > 30 cm3
 TIME TO SURGERY

• Depressed skull fracture

• Depress more than thickness of cranium or > 1 cm
• Dural penetration
• Significant intracranial hemorrhage
• Frontal sinus involvement
• Cosmetic
• Infection and contamination
• Pneumocephalus
 REFERENCES

American college of surgeons committee on trauma. ATLS student course manual. 10th
ed. Chicago: American college of surgeons, 2018.
Carney N et al. Guidelines for the Management of Severe Traumatic Brain Injury,
Fourth Edition. 2016
Anzai Y et al. Imaging of traumatic brain injury. New York: WL, 2015.
Winn, H. Richard. Youmans and Winn’s Neurological Surgery. Phildelphia: Elsevier,
2017.