Head Injury

• Scalp – generous blood supply  major Clasification of traumatic brain injuries

blood loss, hemorrhagic shock, and even
death
• Skull
• Meninges (dura mater, arachnoid mater, and
pia mater)
• Brain (cerebrum, brainstem, and
cerebellum)
• Ventricular system – The presence of blood
in the CSF can impair its reabsorption 
increased ICP. Edema and mass lesions
(hematomas)  effacement or shifting of
the normally symmetric ventricles
(identified on brain CT scans).
• Intracranial compartments
ATLS 10th ed.
Intracranial lesions Management of severe brain injury (GCS score 3-8)
• Diffuse brain injury = hypoxic, ischemic • 10% of patients with brain injury in ED
• Focal brain injury = hematomas, contusions • Unable to follow simple commands, even after
cardiopulmonary stabilization
Intracranial hematomas
• Do not delay patient transfer in order to obtain a CT scan.

ATLS 10th ed.

Management of moderate brain injury (GCS score 9-12)
• 15% of patients with brain injury in ED
• Can still follow simple commands, but usually confused / somnolent
& can have focal neurological deficits such as hemiparesis.
• 10% to 20% of these patients deteriorate & lapse into coma. Serial
neurological examinations are critical in the treatment of these
patients.

ATLS 10th ed.

Management of mild brain injury
(GCS score 13-15)
• A patient who is conscious & talking
may relate a history of
disorientation, amnesia, or transient
loss of consciousness.
• Most patients make uneventful
recoveries. 3% unexpectedly
deteriorate, potentially resulting in
severe neurological dysfunction.

ATLS 10th ed.

 Primary survey & resuscitation
Brain injury often is adversely affected by secondary insults. The presence of
hypoxia & hypotension  increase in the relative risk of mortality of 75%.
• Airway & breathing
• Early ETT in comatose patient
• Ventilate with 100% oxygen until blood gas measurements are obtained,
make appropriate adjustments to the fraction of inspired oxygen (FIO2) 
Goal: oxygen saturations of > 98% (Pulse oximetry).
• Set ventilation parameters to maintain a PCO2 of approximately 35
mmHg.
• Circulation
• If the patient is hypotensive, establish euvolemia as soon as possible using
blood products, or isotonic fluids as needed
• Neurologic exams
• GCS score, pupillary light response, and focal neurological deficit
• Presence of drugs, alcohol, intoxicants, and other injuries
• Comatose  motoric response by pinching trapezius muscles or with nail
bed or supraorbital ridge pressure  for prognostic
• Doll’s eye (N.III), caloric testing with ice (N.VIII) and corneal response
ATLS 10th ed.
 Secondary survey
• Perform serial examinations (GCS
score, lateralizing signs, and pupillary
reaction) to detect neurological
deterioration as early as possible.
• A wellknown early sign of temporal
lobe (uncal) herniation = dilation of
the pupil & loss of the pupillary
response to light.
ATLS 10th ed.
Diagnostic procedures  Head CT scan
• As soon as possible after hemodynamic normalization. Repeated
whenever there is a change in the patient’s clinical status,
routinely within 24 hours of injury for patients with subfrontal/
temporal intraparenchymal contusions, patients receiving
anticoagulation therapy, patients older than 65 years, and
patients who have an intracranial hemorrhage with a volume of
>10 mL.
• CT findings of significance  scalp swelling & subgaleal
hematomas at the region of impact. Skull fractures often
apparent even on the soft-tissue windows (seen better with
bone windows).
• Crucial CT findings  intracranial blood, contusions, shift of
midline structures (mass effect), and obliteration of the basal
cisterns
 A shift of 5 mm or greater = indicates for surgery to evacuate the
blood clot or contusion causing the shift
 Medical Therapies
• IV fluid  Ringer’s lactate solution/normal saline.
• Monitor serum sodium levels in patients with head
injuries (prevent hyponatremia – associated with
brain edema)
• Hyperventilation (only in moderation and for as limited
a period as possible)  by reducing PaCO2 & causing
cerebral vasoconstriction
• Keep the PaCO2 at approximately 35 mmHg
(normal range 35-45 mmHg).
• Hyperventilation will lower ICP in a deteriorating
patient with expanding intracranial hematoma until
doctors can perform emergent craniotomy.
• Mannitol  20% solution (20 g of mannitol per 100 ml
of solution).
• To reduce elevated ICP
• Contraindication = hypotension
• Strong indication = dilated pupil, hemiparesis, or
loss of consciousness
• Bolus mannitol (1g/kg) over 5 minutes
ATLS 10 ed.
th
• Hypertonic saline
• To reduce elevated ICP. Concentrations = 3-
23.4%
• Indication = hypotension
• Barbiturate
• Effective in reducing ICP refractory
• Contraindication = hypotension and
hypovolemia
• Anticonvulsant  Can inhibit brain recovery, so
they should be used only when absolutely
necessary
• Phenytoin and fosphenytoin  mainly used
for acute phase (Dose : 1g IV < 50 mg/min,
maintenance dose = 100mg/8 hours)
• Diazepam or lorazepam added until seizures
stops
Surgical management
• Necessary for scalp wounds, depressed skull
fractures, intracranial mass lesions, and penetrating
brain injuries