Committee on Trauma Presents

Head
Traum
a
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 Objectives

➢ Describe basic intracranial physiology.

➢ Recognize the importance of limiting
secondary brain injury.
➢ Perform a focused neurologic exam.

➢ Stabilize and arrange for definitive

care.

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 Anatomy and physiology effects?

➢ Rigid,nonexpansile skull filled with

brain, CSF, and blood
➢ CBF autoregulation

➢ Autoregulatory compensation
disrupted by brain injury
➢ Mass effect of intracranial

hemorrhage
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 Monro-Kellie Doctrine
Venous Art. Brain CSF
Volum
e Vol.

Ven Art.
Brain Mass CSF
.
Vol. Vol.

75 mL Arterial 75 mL
Brain Mass CSF
Volume

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Volume – Pressure Curve

60-
ICP Herniation
55-
50- (mm Hg)
45-
40-
35- Point of
30-
25- Decompensation
20-
15-
10-
5- Compensation
Volume of Mass
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 Intracranial Pressure (ICP)

➢ 10 mm Hg = Normal
➢ > 20 mm Hg = Abnormal
➢ > 40 mm Hg = Severe
➢ Many pathologic processes affect outcome

➢ Sustained  ICP leads to  brain function

and outcome

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Cerebral Perfusion Pressure*

MBP – ICP = CPP

Normal 90 10 80
Cushing’
s 100 20 80
Response
Hypotension 50 20 30
* CPP  Cerebral Blood Flow
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 Autoregulation

➢ Ifautoregulation is intact, CBF is

maintained with a mean BP of 50 to
160 mm Hg.
➢ Moderate or severe brain injury:
Autoregulation often impaired
➢ Brain more vulnerable to episodes of
hypotension  secondary brain injury

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 Mild Brain Injury

➢ GCS Score = 14–15 ➢ X-rays as indicated

➢ History ➢ Alcohol / drug

➢ Exclude systemic screens as indicated

injuries ➢ Liberal use of head

➢ Neurologic exam CT

Observe or discharge based on findings

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 Moderate Brain Injury

➢ GCS Score = 9–13 Admit and observe

➢

 Frequent neurologic exams

 Repeat CT scan
➢ Initial evaluation

same as for mild

injury
➢ CT scan for all
➢ Deterioration:
Manage as severe
head injury
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 Severe Brain Injury

➢ GCS Score = 3–8

➢ Evaluate and resuscitate

➢ Intubate for airway protection

➢ Focused neurologic exam

➢ Frequent reevaluation

➢ Identify associated injuries

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 Classifications of Brain Injury

By Morphology: Brain
 Epidural (extradural)
Focal  Subdural
 Intracerebral

 Concussion
Diffuse  Multiple contusions
 Hypoxic / ischemic injury
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 Diffuse Brain Injury

➢ Mild concussion  Severe, ischemic

insult

Normal CT Diffuse Injury

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 Contusion / Hematoma

➢ Coup / contracoup injuries

➢ Most common: Frontal / temporal lobes

➢ CT changes usually progressive

➢ Most conscious patients: No operation

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Contusion / Hematoma

Large frontal
contusion with
shift

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 Epidural Hematoma

➢ Associated with skull fracture

➢ Classic: Middle meningeal artery tear

➢ Lenticular / biconvex
➢ Lucid interval

➢ Can be rapidly fatal

➢ Early evacuation essential

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Epidural Hematoma
Temporal
Epidural
Hematoma

Uncal
herniation

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 Subdural Hematoma

➢ Venous tear / brain laceration

➢ Covers cerebral surface
➢ Morbidity / mortality due to underlying
brain injury
➢ Rapid surgical evacuation
recommended, especially if > 5 mm
shift of midline

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Subdural Hematoma

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 Priorities

➢ ABCDE

➢ Minimize secondary brain injury

 Administer O2
 Maintain blood pressure
(systolic > 90 mm Hg)

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 Focused Neurologic Exam?

➢ GCS Score
➢ Pupils

➢ Lateralizing signs

Consult neurosurgeon early

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Indications for CT
Scan?

All patients with

suspicion of brain
injury

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 Medical Management

➢ Intravenous fluids
 Euvolemia
 Isotonic
➢ Controlled ventilation
 Goal: Paco2 at 35 mm Hg

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 Medical Management

➢ Mannitol
 Use with signs of tentorial herniation
 Dose: 1.0 g / kg IV bolus
 Consult with neurosurgeon first

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 Medical Management

➢ Other medications
 Anticonvulsants
 Sedation
 Paralytics

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 Surgical Management

Scalp Injuries
➢ Possible site of major blood loss
➢ Direct pressure to control bleeding
➢ Occasional temporary closure

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 Surgical Management

Intracranial Mass Lesion

➢ May be life-threatening if expanding
rapidly
➢ Immediate neurosurgical consult
➢ Hyperventilation / Mannitol

➢ Damage control craniotomy: Transfer

to neurosurgeon (rural / austere areas)
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?
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 Summary: What should I
do?
➢ Maintain mean BP > 90 mm Hg
➢ Maintain Paco2 near / at 35 mm Hg

➢ Use isotonic solution for euvolemia

➢ Frequent neurologic exams
➢ Liberal use of CT scans

➢ Early neurosurgical consult

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 Summary: What should I not
do?
➢ Allow patient to become hypotensive
➢ Over-aggressively hyperventilate

➢ Use hypotonic IV fluids

➢ Use long-acting paralytics

➢ Paralyze before performing complete exam

➢ Depend on clinical exam alone

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