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Head Trauma
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Objectives

Describe basic intracranial physiology.

Evaluate the head / brain-injured patient.
Perform necessary stabilization
procedures.
Determine appropriate disposition.
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Head Injury

Common problem
High morbidity and mortality
Secondary insults
Worsen outcome
Often preventable
Early neurosurgical consult and transfer
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Neurosurgeon Needs to Know

Age and history

Vital signs
GCS score and pupils
Alcohol / drug(s) intake
Associated injuries
Brain CT
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Intracranial Pressure (ICP)

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

CBF maintained Mean BP of 50 to

160 mm Hg
Moderate or severe brain injury

autoregulation often impaired

Brain more vulnerable to episodes of

hypotension
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Cerebral Blood Flow

50 mL/100 g/min Normal

< 25mL/100 g/min EEG activity
5 mL/100 g/min Cell death
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Classifications of Head injury

Blunt High velocity
By Low velocity
Mechanism
GSW
Penetrating Other

GCS = 14-15
Mild

By Moderate GCS = 9-13

Severity
Severe GCS = 3- 8
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Classification of head injury

By Morphology
Linear vs stellate
Vault Depressed/ nondepressed
Skull Open
Fracture
Basilar With / without CSF leak
With / without cranial
palsy
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Basal Skull Fracture

CSF rhinorrhea : Retroauricular
anterior skull base ecchymosis
CSF otorrhea : Mid Facial nerve
skull base injury
Hemotympanum Loss of hearing
Periorbital
Pneumocephalus
ecchymosis
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Classifications of Head Injury

By Morphology
Epidural
Subdural
Focal Injury
Intracerebral

Mild concussion
Diffuse Injury
Classic concussion
Diffuse axonal injury
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Epidural Hematoma

Associate with skull fracture

Classic : Middle meningeal artery tear

Lenticular / biconvex due to dural

adherence to skull
Lucid interval
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Epidural Hematoma

Can be rapidly fatal

Early evacuation prognosis
Venous epidurals : Possible nonsurgical
management
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Subdural Hematoma
Venous tear / brain laceration
Covers entire cerebral surface
Morbidity / mortality due to underlying
brain injury
Rapid surgical evacuation recommended,
especially if > 5 mm shift of midline
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Contusion / Hematoma

Coup / contrecoup injuries

Most common :

Frontal /temporal lobes

Salt and pepper appearance on CT

CT changes usually progressive

Most conscious patients : No operation

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Concussion
Transient loss of consciousness
Normal Head CT
Nausea vomiting
Headache: if severe, repeat CT
Symptoms may worsen before
improvement
Sequelae common
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Diffuse Axonal Injury

Prolonged deep coma (not due to mass

lesion)
Diffuse brain injury
Motor posturing
Frequent autonomic dysfunction
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Mild Brain Injury

GCS Score = 14-15 X-ray 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

Initial evaluation Frequent
same as for mild neurologic exams
injury Repeat CT scan
CT scan for all Deterioration :
Manage as severe
head injury
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Severe Brain Injury

GCS Score = 3-8
Evaluate / resuscitate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Identify associated injuries
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Severe Brain injury

Airway / Breathing
Airway protection
Supplemental oxygen
Assisted ventilation
Modest hyperventilation if
necessary (PaCO2 at 25-35mm Hg)
Frequent reevaluation / ABGs
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Severe Brain Injury

Circulation
Hypotension not due to brain injury
Hypotension causes secondary brain injury
Correct hypotension quickly
Do not treat BP, maintain CPP
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Severe Brain Injury

Disability
GCS
Eye opening
Best motor response
Verbal response
Pupillary size equality, reaction to light
Symmetry of motor strength
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Severe Brain Injury

Disability
Minineurologic exam
On patient arrival
After resuscitation
Frequently
Document changes
Consult neurosurgeon early
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Severe Brain Injury

Cause
IIIrd Nerve compression
bilaterally
Inadequate CNS
perfusion

IIIrd nerve compression,

tentorial herniation
Optic nerve injury
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Severe Brain Injury

Cause
Drugs
Pontine lesion

Injured sympathetic
pathway
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Severe Brain Injury - Herniation

Deteriorating LOC (GCS score)

Pupillary asymmetry
Motor asymmetry
Cardiopulmonary arrest
Cushings triad
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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
Hyperventilation, if necessary
Goal : PaCO2 at 25-35 mm Hg
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Medical Management
Mannitol
Use with signs of tentorial herniation
Dose : 0.5 1.0 g/kg IV bolus
Other
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
? Emergency burr holes ?
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Question
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Summary : Prescription (Do)

Maintain mean BP > 90 mm Hg
Maintain PaCO2 between 25 - 35 mm Hg
Use isotonic solution for euvolemia
Frequent neurologic exams
Liberal use of CT scans
Early neurosurgical consult
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Summary : Proscription (Dont)

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