Head Injury

Dr. Farhad Bal’afif, SpBS

Bedah Saraf FKUB/RSSA Malang
Head Injury
• Scalp injury
• Skull injury
• Meningeal injury
• Traumatic Brain Injury
 Epidemic in Indonesia
 Major cause of death and permanent

disability
 70% of all road fatalities
 50% of trauma death
 10-20% of head injury: death on arrival
 Degree 70% mild head injury

15% moderate head injury

15% severe head injury
 Severity of primary injury
 Intracranial complications
 Hypoxaemia
 Hypercarbia
 Hypotension
 Anaemia
 Multiple injuries, proportional to Injury

Severity Score (ISS)

 Age
 Prolonged prehospital time
 Admission to inappropriate hospital
 Delayed or inappropriate interhospital

transfer/retrieval
 Delay in definitive surgical treatment
 Traumatic Brain Injury

Blunt(Closed) Penetrating

Explosion Fall GSW Stab

Blast
Fragment

Motor vehicle crashes (MVC)

1. Headache
2. Vomiting
3. Papilloedema occur in chronic condition
4. Cushing response
◦ Bradicardia
◦ Hipertension
◦ Alteration of ventilatory pattern
5. Herniation
• Uncal - ipsilateral dilated pupil
- contralateral hemiparesis
- ipsilateral hemiparesis
(Kernohan’s notch phenomenom)
• Central - rostrocaudal sign
• Subfalcine
• Tonsiller herniation
 Mild – GCS 14-15
Patient typically mildly lethargic, disoriented
 Moderate – GCS 9-13
Patient typically sleepy or obtunded, able to follow
commands with arousal.
Confused.
 Severe – GCS 3-8
Patient comatose, unable to follow command or
perform purposeful motor activity.
Range of motor activity: localizes, withdraws,
decorticate posturing, decerebrate posturing, nil.
 Primary Injury: Function of energy transmitted to brain
◦ Very little can be done by health care providers to influence
◦ Cerebral concussion, contusion and degeneration, Diffuse Axonal
Injury (DAI)
 Secondary Injury: Function of damage to brain from systemic
physiology
◦ Systemic
 Hypotension: Acute and easily treatable
 Hypoxia: Acute and easily treatable
 Fever and Electrolyte Imbalances
◦ Seizures
◦ Intracranial Pressure  Can Lead to Herniation
 Primary
Scalp
contusion, abrasion, laceration
Skull fracture
open, closed (note-compound base of skull fracture
without a scalp laceration), linier, depressed
Meningeal injury
dural tear
Brain injury
concussion
contussion
diffuse axonal
focal – contusion
laceration and penetration
 Secondary

Intracranial haemorrhage
Cerebral swelling
cerebral hypoxia
CSF leakage and pneumocephalus
methabolic disorders
infection
epilepsy
 Factors influencing outcome
- airway
- breathing
- control of haemorrhage
- prevention and shock treatment
- avoidance of factors ↑ ICP
• head down position
• hypoxia
• hypercarbia
• vomiting
- recognition of serious associated injury
- effective communication and transport
 Lateral position for airway control
in Px with susp spinal injury

 The face in turned slightly down words

the tongue to fall forwards
saliva and vomit will drain out
 The indication:
◦ Airway is inadequate
◦ GCS ≤ 8
◦ Herniation
◦ Rapid deterioration
Should be performed only by a competent medical
practitioner
 Gambar COB dgn ETT
Early management of severe trauma
The management plan is based on:
1. Primary survey
2. Resuscitation
3. Secondary survey
4. Definitive care
 Primary survey
◦ Airway with cervical spine immobilized in neutral
position
◦ Breathing pattern and adequacy
◦ Circulation and haemorrhage
◦ Disability, minineurological examination:
 GCS
 Pupils
 Motor deficit
◦ Exposure: completely expose the patient for an
adequate examination but protect against
hypothermia
 Resuscitation
◦ Airway
 Ensure patient airway
 Unconscious patient: intubated if skilled
 Note: maintain cervical spine immobilization until
radiological examination excludes spinal injury
◦ Breathing and oxygenation
 Ensure adequate ventilation
 Mechanically ventilate if intubated
 Give supplemental oxygen initially
◦ Circulation support and control
haemorrhage
 Treat shock aggressively to improve
tissue perfusion
 Control external haemorrhage
◦ Assess response to resuscitation using
physiological parameters: pulse, blood
pressure, skin colour, capilary refill and
urine output
◦ Nasogastric tube and urinary catheter
unless contraindicated
◦ Head injury alone, without scalp injury,
does not cause hypotension. If
hypotension is present, identify the cause,
e.g.:
• Hypovolaemic shock,
• spinal injury.
• Rarely, may be due to medulallary failure.
• Blood loss from a scalp or head injury
may cause hypotension (hypovolaemic
shock) in children
 Secondary survey
◦ History
◦ Special neurosurgical assessment including
Glasgow Coma Score (GCS) and external sign of
injury to the head
◦ Record the pulse, blood pressure, respiratory rate
and temperature
◦ Systematically examine each region of the body, i.e.
head-to-toe examination
◦ Connect to monitors as available
◦ Re-evaluate the GCS
◦ Radiological examination-lateral X-ray spine, chest,
pelvis, other areas as indicated, skull X-ray and CT
head scan
 CNS examination
◦ Glasglow Coma Scale (GCS)
◦ Pupillary responses
are they equal or unequal? Were the pupils equal
at the time of the incident (report from
ambulance officer) and have they the same
response now?
◦ Motor pattern
hemiparesis, quadriparesis
flexion or extension to pain (from supraorbital,
trapezius or tendo achilles pressure)
◦ Inspection of the face and scalp
◦ Palpation of the face and scalp and any laceration
for a depressed fracture
◦ Palpation of the spine for the tenderness and
deformity
Glasgow Coma Scale (GCS)
This scale examines three areas of behaviour: eye
opening, response to voice and motor responses.
The score can be quantitative with 3 being the
lowest score and 15 normal
 Eye opening
◦ Spontaneous E4
◦ To speech 3
◦ To pain 2
◦ Nil 1
 Verbal response
◦ Orientated V5
◦ Confused conversation 4
◦ Inappropriate words 3
◦ Incomprehensible sound 2
◦ Nil 1
 Best motor response
◦ Obeys M6
◦ Localizes 5
◦ Withdraws 4
◦ Abnormal flexion 3
◦ Extension 2
◦ Nil 1
 Coma Score (E+V+M) = 3-15
 CT head scan guidelines
◦ GCS < 15 after resuscitation
◦ Neurological deterioration, i.e 2 point or more on
the GCS, hemiparesis, squint
◦ Drowsiness or confusion (GCS 9-14 persisting>2 h)
◦ Persistent headache, vomiting
◦ Focal neurological signs
◦ Fracture – known or suspected
◦ Penetrating injury – known or suspected
◦ Age – over 50 years of age
◦ Post-operative assessment
 Skull X-ray guidelines
In rural area where a CT scan is not available or
readily accessible, a plan skull X-ray can provide
useful information. The pictures required are AP,
lateral, Towne’s view and tangential to the point of
impact for demonstrating a depressed fracture
 Indications
◦ Loss of consciousness, amnesia
◦ Persisting headache
◦ Focal neurological signs
◦ Scalp injury
◦ Suspected penetrating injury
◦ CSF or blood from nose or ear
◦ Palpable or visible skull deformity
◦ Difficulty in clinical assessment
◦ Patient with GCS 15, essntially asymptomatic but
“at risk” bacause of a defect blow or fall onto a hard
surface, etc, especially in a patient over 50 years of
age
Criteria for admission to hospital with head injury:
• Confusion or any other decreased level of consciousness or a
period of post-traumatic amnesia
• Neurological symtoms or sign – including persistent headache,
vomiting
• Difficulty in clinical assessment, e.g. alcohol, epilepsy
• Other medical condition, e.g. coagulation defects, diabetes
mellitus
• Skull fracture
• Abnormal CT brain scan
• Responsible observation not available outside the hospital
• Age – patients over 50 years of age
• Children under 5 years of age
 Discharge of minor head injury patient
◦ Orientated in time and place
◦ No focal neurological signs
◦ No skull fracture
◦ A responsible person is available to continue observation of
the patient
◦ Discharge check list – advise to report back to hospital
immediately if there is:
a) Vomiting
b) Complains of severe headache or dizziness
c) Becomes restless, drowsy or unconscious
d) Had a convulsion or fit
 Intubate & ventilate with GCS<9
 the goal: PaO2=100mmHg, PaCO2 35mmHg, O2 sat
96%,
 hyperventilation (PaCO2< 30mmHg) should be avoided
 Cerebral perfusion
 the goal: CPP>70mmHg, MAP>90mmHg
 hypotension (systolic BP<90mmHg) must be avoided
 Intravenous fluid electrolites
 normovolaemic is the goal,
 avoid dehydration on or ever hydration
 normal serum electrolyte should be maintaned
 Head posture: should be elevated to 20-30°

 Corticosteroid: are not recommended

 Transfer to CT and / or neurosurgical unit
 Active treatment of intracranial pressure
Only be under taken of there is evidence of
- rapid neurological deterioration
- signs of uncal herniation
- ↑ ICP from the ICP monitoring
- modality (should be decided by neurosurgeon)
• CSF drainage
• intravenous mannitol
• hyperventilation
• barbiturate
• mild hypothermia
• decompressive craniectomy
Prevention of intracranial infection
This can result from basal skull fracture or from a
penetrating craniocerebral injury. CSF rhinorrhoea
or otorrhoea, intracranial aerocele or a known or
suspected penetrating injury require careful
assessment. The indication for prophylactic
antibiotic therapy is controversial. A neurosurgical
consultation is indicated.
1. CSF rhinorrhoea or otorrhoea – swab for culture
and sensitivity and observe
2. Intracranial aerocele – antibiotic therapy
3. Penetrating craniocerebral injury – surgical repair
and antibiotic therapy
Restlessness and analgesia
o Before prescribing analgesia, it is important to
determine the cause of restlestness, e.g.:
 cerebral hypoxia from airway inadequacy or poor ventilation
or poor perfusion,
raised intracranial pressure,
pain,
alcohol intoxication or a
full bladder.

oDrugs other than paracetamol or codeine

phosphate require neurosurgical consultation
 Post traumatic epilepsy
 The risk factors for epilepsy are:
 intradural haematomas,
 dural laceration with cortical injury,
 depressed fractures,
 a post-traumatic amnesia period of 24 h early post
traumatic epilepsy

 The indication for prophylactic anti-convulsant therapy is

controversial. A neurosurgical consultation is indicated both
for the cause of the epilepsy and for consideration for anti-
convulsant therapy.
 Admit to ICU
 Cond: critical
 Vitals q1hr w/ neuro checks (if on Propofol, stop and check q4 hrs)
 Bedrest, HOB to 30*, loosen c-collar when patient sedated
 NPO
 IVF
◦ NS or ½ NS w/ 20 K @ 80-100 cc/hr
◦ If significant brain edema, start 3%NS @ 15/hr, increase up to 50/hr (keep serum Na at 145-155, serum osmol 300-320)
 Vent
◦ No or low PEEP
◦ Keep PaCO2 at 30-35 (see hyperventilation above)
 Meds
◦ Propofol drip or Ativan 2-10mg iv q1hr for sedation or ICP>20 for>5’
◦ MSO4 2-10 mg iv q1hr prn pain or ICP>20 for>5’
◦ Mannitol 25g iv q4hrs prn ICP>20 for>5’ (hold if serum Na >155 or osmol>320)
◦ Cerebyx 1g iv now (loading dose), then 100mg q8
◦ Pepcid 20mg iv bid
◦ Ancef 1g iv q8 if scalp wound or ICP monitor
 Nursing – per ICU routine
 Labs
◦ CBC, CMP, Dilantin level qAM
◦ Serum Na and osmol q6 if on 3% NaCl or Mannitol
 Repeat head CT in am (at least 2 CTs per patient, one on arrival and one next day)
 Call for problems
 Do NOT use D5; use NS or ½ NS w/ 20 KCl
 Keep them euvolemic to dry (about 1cc/kg/hr)
 If brain edema is an issue, keep serum Na above 140

◦ Mannitol and/or
◦ 3% saline (start at 15cc/hr, increase up to 50/hr)
◦ Check serum Na and osmol q6 hrs – do not exceed serum Na
of 155 or serum osmol of 320
 Absence of brainstem reflexes
◦ Fixed pupils
◦ Absent corneal reflexes
◦ Absent oculovestibular reflex (cold water calorics)
◦ Absent oculocephalic reflex (not if C-spine not cleared)
◦ Absent gag and cough reflex
 No response to deep central pain
 Apnea test (last test to perform!)
 Vital signs
◦ Core temp > 32.2*C (90*F)
◦ SBP>90 mm Hg
 No drugs in the system!
 Nursing assessment
◦ Glasgow Coma Scale score
◦ Neurologic status
◦ Presence of CSF leak
 Nursing diagnoses
◦ Ineffective tissue perfusion
◦ Hyperthermia
◦ Acute pain
◦ Impaired physical mobility
◦ Anxiety
 Collaborative problem: Increased ICP
 Planning
◦ Overall goals
 Maintain adequate cerebral perfusion
 Remain normothermic
 Be free from pain, discomfort, and infection
 Attain maximal cognitive, motor, and sensory function
 Nursing implementation
◦ Health promotion
 Prevent car and motorcycle accidents
 Wear safety helmets and seat belts
 Nursing implementation
◦ Acute intervention
 Maintain cerebral perfusion
 Prevent secondary cerebral ischemia
 Monitor for changes in neurologic status
 Treatment of life-threatening conditions will initially
take priority in nursing care
 Nursing implementation
◦ Acute intervention
 Major focus of nursing care relates to increased ICP
 Eye problems
 Hyperthermia
 Raise the head of patients leaking CSF
 Nursing implementation
◦ Ambulatory and home care
 Nutrition
 Bowel and bladder management
 Spasticity
 Dysphagia
 Nursing implementation
◦ Ambulatory and home care
 Seizure disorders
 Personality changes
 Family participation and education
 Evaluation

◦ Expected outcomes
 Maintain normal cerebral perfusion pressure
 Achieve maximal cognitive, motor, and sensory
function
 Experience no infection or hyperthermia
 Achieve pain control
Figure 1. Treatment Algorithm: Clinical Practice Guidelines for the Nursing Management of Adults with Severe TBI
Craniotomy Review
Definitive management of traumatic brain
injury
◦ Immediate surgery for evacuation of hematoma, if
necessary
◦ Monitor ICP with implanted pressure gauge
◦ Medically manage cerebral edema to maintain
cerebral perfusion pressure > 70 mmHg
◦ Perform serial head CT Scans
20% of cerebral contusions may enlarge to
surgical hematoma
Quantity Name Description  Size 
2 Jansen Retractor Blunt 3x3 Blades 4"
2 Weitlaner Retractor Blunt 3x4 Teeth 6-1/2"
1 Scalpel Handle #3    
1 Scalpel Handle #4    
1 Scalpel Handle #7    
4 Solid Bar Handle For Gigli Saw Pack of 2  
2 Adson (Ewald) Dressing Forceps Serrated 4-3/4"
2 Adson Tissue Forceps 1x2 Teeth 4-3/4"
12 Backhaus Towel Clamp   5-1/4"
2 Cushing Brain Forceps Delicate Serrated 7"
2 Cushing Brain Forceps Delicate 1x2 Teeth 7"
6 Ruskin Rongeur Straight 7-1/4"
6 Foerster Sponge Forceps Serrated 9-1/2"
18 Halsted Mosquito Forceps Straight 5"
18 Halsted Mosquito Forceps Curved 5"
1 Luer Bone Rongeur Curved 8mm x 10mm Bite 7"
1 Stille-Liston Bone Forceps Curved Double Action 10-1/2"
2 Mayo-Hegar Nh Serrated 7"
1 Gigli Saw Wire   12"
1 Gigli Saw Wire   20"
1 Operating Scissors Straight Sharp/Blunt 6"
1 Mayo-Stille Dissecting Scissors Straight 6-3/4"
1 Mayo-Stille Dissecting Scissors Curved 6-3/4"
1 Metzenbaum Dissecting Scissors Curved 7"
1 Taylor Dural Scissors w/ Probe Tip 5-1/2"
1 Cover for Instrument Tray    
 Labs: CBC, lytes, Cr, INR/PTT
 Crossmatch (at least 2 U PRBC)

 2 physician consent

 Spinal precautions
◦ May need to log roll patient
 Scalp Incision
◦ Large question mark incision
starting 1 cm in front of tragus at
zygomatic arch & curved backward &
upward above auricle to reach
midline, carried forward to frontal
region
◦ Raney clips along skin edges
◦ Bovie incision in superficial temporal
fascia & temporalis muscle down to
the bone, close to margin of skin
opening
◦ Myocutaneous flap reflected
inferiorly

 Rapid Temporal Decompression

◦ In patient who is herniated or is
deteriorating, temporal end of
incision rapidly opened & burr hole
placed
◦ Burr hole is then enlarged to form a
limited craniectomy 3 cm in
diameter
◦ If hematoma in subdural space, dura
is opened in a cruciate manner &
underlying hematoma is promptly
evacuated – helps to reduce ICP
before completion of craniotomy
which can then be completed more
slowly, w/ better hemostasis
 Bone Flap
◦ Burr holes, then join burr holes to
complete craniotomy opening
◦ Medial margin 1.5~2 cm from
midline
◦ Further exposure of middle fossa
obtained using Leksell rongeurs to
remove parts of lateral sphenoid
wing & temporal bone in piecemeal
fashion, as needed for temporal tip
access
 Dural Opening
◦ Opening in U-shaped fashion & flap
towards midline to avoid damaging
parasagittal bridging veins
◦ Alternatively, cruciate opening

 Closure
◦ Meticulous hemostasis
◦ Dural tack-up sutures 2.5 cm apart
in circumferential fashion & central
tack-up suture in bone flap
◦ +/- drain
THANK YOU