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Brain Trauma

Fanny Indarto,dr.,Sp.B

Mechanisms
Blunt and Penetrating Trauma
occurs from motor vehicle accidents, falls, assault, and
industrial accidents. Gunshot or missile wounds and stab
wounds result in penetrating trauma.
Primary Brain Injury
Primary brain injury occurs at impact and is irreversible.
Secondary or Delayed Brain Injury
a result of several factors, including development of
intracranial hematomas, contusions, cerebral edema,
anoxia and other metabolic abnormalities, hydrocephalus,
infections, pneumocephalus, seizures, and so forth.
Secondary injury is often preventable and, in many
cases, reversible.

Classification
Mild: GCS of 14 to 15; loss of
consciousness, if present, is brief (<5
minutes)
Moderate GCS of 9 to 13
Severe: GCS of 8, which, by
definition, is coma

Glasgow Coma Scale

History
Mechanism of Injury
information on the speed at which the motor vehicle accident (MVA)
occurred, vehicular damage, restraints, ejection from vehicle, assault
weapon, type of missile or firearm, alcohol or substance use, and so on.
On-Scene Neurologic Examination
Information from emergency personnel must be obtained, when
available. Loss of consciousness, changes in neurologic examination while
en route to the ER, history of nausea or vomiting, side of the pupil to
dilate first, and so on must be elicited.
Time Course of Events
Determine the possibility of multisystem trauma and so on.
Neurologic Symptoms
Consider any neurologic symptoms described by patient (headache,
changes in vision, speech, hearing, motor strength or sensation, pain in
neck or spine).
Alcohol or Substance Use

Examination

Vital signs
Dilated pupil
Level of Consciousness or Cognition (Glasgow Coma Scale)
Inspection
Cranial nerve exam
Pupil
Vision
Ocular movement
Facial motor and sensory functions
Hearing and equilibrium
Limbs
Spine

A combination of hypertension, bradycardia,


and respiratory irregularity (Cushing reflex)
indicates transtentorial herniation.
Hypotension is unlikely to result from head injury,
except: neonates or infants who can lose
significant proportion of total blood volume in an
intracranial hemorrhage and adults with significant
loss of blood from scalp injuries or associated
spinal cord injury with neurogenic shock.
Hypothermia needs to be treated because it will
worsen coagulopathy and alter neurologic status.

Unilateral or bilateral, a dilated pupil is a


surgical emergency.
lacerations or defects in scalp, periorbital
ecchymoses (raccoon eyes), and retroauricular
ecchymoses (Battle's sign) indicative of
anterior cranial skull base and petrous
temporal fractures
Bleeding in the ear canals or cerebrospinal fluid
(CSF) otorhinorrhea can also indicate skull
fractures and increased risk of ascending
infection.

Diagnostic studies

Skull radiograph
Head CT scan
MRI
Cerebral angiogram
Nuclear cerebral perfusion studies

Management

Head elevation
Avoid Hypothermia
Maintain Normovolemia
Nothing by Mouth
Orotracheal Intubation and Assisted Ventilation
Avoid Jugular Venous Compression
Serial Monitoring
Electrolytes, blood gasses, osmolality, serum levels
of antiepileptic drugs, and coagulation parameters
must be monitored serially.
Maintain Normotension

Continuous Intracranial Pressure


Monitoring
Steroids
Antiemetics and Mild Analgesics
Antiepileptic Treatment
Intravenous Mannitol
Hypertonic Saline
Short-Acting Sedatives and Paralytics
Hyperventilation

Decompressive Surgery in Severe


Refractory Intracranial Hypertension
Pentobarbital Therapy

Subdural Hematomas
which occurs in 20% to 40% of severely
head-injured patients.
This lesion originates in the space between
the dura and arachnoidal meningeal layer
on the surface of the brain and is a result
of injury to the bridging veins and the
brain parenchyma beneath it.
As it layers on the surface of the brain it
forms a crescent shape

The morbidity of subdural


hematomas is due to the rapid
onset of mass effect as well as
injury to the brain parenchyma
beneath the subdural

Subdural hematoma

Epidural hematomas
epidural hematomas have a lens shape, formed as the
blood peels the dura back, creating a pocket of blood
trapped between the inner table and the dura.
caused by lacerations of the middle meningeal
artery caused by fractures in the temporal bone,
which is extremely thin and susceptible to fracture.
can also be caused by lacerations to the dural
sinuses or fractures through the diploic spaces,
causing venous bleeding into the epidural space.
Epidural hematomas are more the result of skull injury
than of brain injury

In fact, only about 1/3 of patients


with epidural hematomas actually
experience this lucid interval and
it may also occur with other
intracranial bleeds, making it an
alarming but nonspecific finding.

Intracerebral Hematoma

Subarachnoid Hematoma