Head Trauma

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

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Head Trauma -
Discussion

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Head Trauma -
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
• 50% of motorcycle fatalities

Assume spinal injury with serious injury

• Potential for altered mental status

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Head Trauma -
Brain Physiology
Intracranial pressure (ICP)
• Pressure of brain and contents in skull
• <10-15

Cerebral perfusion pressure (CPP)

• Pressure required to perfuse brain
• 60-100 (MAP – CVP)

Mean arterial pressure (MAP)

• Pressure maintained in vascular system
• Systolic pressure + 2(diastolic pressure)/3
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Head Trauma -
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

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Head Trauma -
Head Trauma
Open
• Skull compromised
and brain exposed

Closed
• Skull not compromised
and brain not exposed

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Head Trauma -
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

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Head Trauma -
Head Injuries
Skull fracture
• Linear nondisplaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Management
• Dressing, avoid excess pressure
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Head Trauma -
Basilar Skull Fracture
Battle’s sign Raccoon eyes

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Head Trauma -
Head Injuries
Penetrating trauma

Bullet fragments
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Head Trauma -
Forces that cause skull fracture
can also cause brain injury.

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Head Trauma -
Brain Injury
Primary brain injury
• Immediate damage
due to force
• Coup and contracoup
• Fixed at time of injury

Management
• Directed at prevention

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Head Trauma -
Brain Injury
Secondary brain injury
• Results from hypoxia
or decreased perfusion
• Response to primary injury
• Develops over hours

Management
• Good prehospital care can help prevent

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Head Trauma -
Brain Injury
Response to injury
• Swelling of brain
• Vasodilatation with increased blood volume
• Increased ICP

• Decreased blood flow to brain

• Perfusion decreases
• Cerebral ischemia (hypoxia)

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Head Trauma -
 Early efforts
to maintain brain perfusion
can be life-saving.

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Head Trauma -
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, ringing in ears, and/or nausea

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Head Trauma -
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

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Head Trauma -
Brain Injuries
Subarachnoid hemorrhage
• Blood in subarachnoid space
• Intravascular fluid “leaks” into brain
• Fluid “leak” causes more edema

• Associated symptoms
• Severe headache
• Coma
• Vomiting
• Cerebral herniation syndrome possible

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Head Trauma -
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

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Head Trauma -
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

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Head Trauma -
Brain Injuries
Intracranial hemorrhage
• Epidural
• Between skull and dura

• Subdural
• Between dura and arachnoid

• Intracerebral
• Directly into brain tissue

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Head Trauma -
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
• Unilateral dilated fixed pupil, signs of increasing ICP,
unconsciousness, contralateral paralysis, death

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Head Trauma -
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

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Head Trauma -
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

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Head Trauma -
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.

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Head Trauma -
Head Trauma Assessment
BTLS Primary and Secondary Surveys

Limit patient agitation, straining

• Contributes to elevated ICP

Airway
• Vomiting very common within first hour
• Endotracheal intubation
• IV lidocaine no longer recommended
• Nasotracheal or RSI

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Head Trauma -
Pupils
Both dilated
• Nonreactive: brainstem
• Reactive: often reversible
Eyelid closure
• Slow: cranial nerve III
• Fluttering: often hysteria
Anisocoria
Unilaterally dilated
• Reactive: ICP increasing
• Nonreactive (altered LOC):
increased ICP
• Nonreactive (normal LOC): not
from head injury
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Head Trauma -
Extremity Posturing
Decorticate
• Arms flexed
and legs extended

Decerebrate
• Arms extended
and legs extended

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Head Trauma -
 Glasgow Coma Scale
Suspect severe brain injury GCS <9

*Decorticate posturing to pain

**Decerebrate posturing to pain
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Head Trauma -
Increasing ICP
Vital Sign Change with Increasing ICP
Respiration Increase, decrease, irregular
Pulse Decrease
Blood pressure Increase, widening pulse pressure

Cushing’s response
• As ICP increases, systolic BP increases
• As systolic BP increases, pulse rate decreases

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Head Trauma -
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

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Head Trauma -
The Injured Brain
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
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Head Trauma -
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

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Head Trauma -
Hyperventilation
Cerebral herniation syndrome
• Herniation danger outweighs hypoxia

Indications for hyperventilation

• TBI GCS <9 with decerebrate posturing
• TBI GCS <9 with dilated or nonreactive pupils
• TBI initial GCS <9, then drops >2 points

If signs resolve, stop hyperventilation.

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Head Trauma -
Hyperventilation Rates
Age Group Normal Rate Hyperventilation
Adult 8–10 per minute 20 per minute
Children 15 per minute 25 per minute
Infants 20 per minute 30 per minute

Capnography
• Maintain EtCO2 <30 mmHg, but >25 mmHg

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Head Trauma -
Cerebral Herniation

Is ICP severe enough

to outweigh cerebral ischemia?

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Head Trauma -