C ED ER A K EPA LA

ATLS ATLS ATLS ATLS ATLS ATLS

Sherly tandililing, dr

Common problem
High morbidity and
mortality

AN ATO M I

M EN IN G EN

LCS

Intracranial P ressure (IC P )

10mm Hg
= Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe
Many pathologic processes affect
outcome
ICP Brain function,outcome

M O N RO -KELLIE

C erebral B lood Flow

50 mL/100 g/min normal

< 25mL/100 g/min EEG activity
5 mL/100 g/min Cell death

C lassif c
iations of H ead injury
Blunt
By
Mechanism
Penetrating

Mild
By
Moderate
Severity
Severe

High velocity
Low velocity
GSW
Other
GCS = 14-15
GCS = 9-13
GCS = 3- 8

C lassif c
iations of H ead Injury
By Morphology
Focal Injury:
Epidural
Subdural
Subarachnoid
Intracerebral
Diffuse Injury

Epidural H em atom a

Associate with skull fracture

Classic : Middle meningeal artery
tear
Lenticular/biconvex due to dural
adherence to skull
Lucid interval

Subdural H em atom a

Venous tear /brain laceration

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

D if u
f se A xonal Injury

Prolonged deep coma (not due to

mass lesion)
Diffuse brain injury
Normal CT

M anagem ent B rain injury

Airway / Breathing
Airway protection
Supplemental oxygen
Assisted ventilation if
necessary
(Paco at 25-35mm Hg)

Frequent reevaluation/ABGs

Circulation
Hypotension not due to brain injury
Hypotension causes secondary
brain injury
Correct hypotension quikly
Do not treat BP, maintain CPP

Disability
GCS
Eye opening
Best motor response
Verbal response

Pupillary size equality, reaction to

light
Symmetry of motor strength

Disability
Minineurologic exam
On patient arrival
After resusciation
Frequently

Document changes

Cause
IIIrd Nerve
compression
bilaterally
Inadequate CNS
perfusion

IIIrd nerve
compression
tentorial
herniation

Cause
Drugs
Pontine lesion

Injured
sympathetic
pathway

H erm ation

Deteriorating LOC (GCS score)

Pupillary asymmetry
Motor asymmetry
Cardiopulmonary arrest
Cushings triad

M edical M anagem ent

Intravenous fluids
Euvolemia
Isotonic

Hyperventilation, if necessary
Goal : PaCO at 25-35 mm Hg

Mannitol
Use with signs of tentorial

herniation
Dose : 0.5 1.0 g/kg IV bolus

Other
Anticonvulsants
Sedation
Paralytics

Surgical M anagem ent

Scalp injuries
Possible site of major blood loss
Direct pressure to control bleeding
Intracranial Mass Lesion
May be life threatening if expanding
rapidly
Immediate neurosurgical consult
Hyperventilation / Mannitol
? Emergency burr holes ?