HEAD TRAUMA

1
CHAPTER 6

• HEAD TRAUMA

2
OBJECTIVES

• A. Understand basic intracranial anatomy
  physiology
• B. Evaluate a patient with a head injury
• C. Perform the necessary stabilization
• procedures
• D. Determine the appropriate disposition of
  the patient

3
Introduction

• 10 of head injury die prior to reaching a
  hospital
• Head injury can be divided
• mild ( 80 )
• moderate (10 )
• severe (10 )
• avoid secondary brain damage ( support vital
  signs, avoid treat IICP )
• Obtaining a CT Scan should not delay patient
  transfer ( transfer patient early )
• Neurosurgical consult essential

4
Neurosurgen need know

• 1. Age of patient the mechanism and time of
  injury
• 2. Vital signs ( particular the blood pressure )
• 3. Results of minineurologic examination ( GCS
  score particular the motor response, and
  pupillary reaction )
• 4. Associated injury
• 5. Results of the diagnostic studies ( CT scan )

5
Anatomy Physiology

• SCALP
• S Skin
• C Connective tissue
• A Aponeurosis / galea aponeurotica
• L Loose areolar tissue
• P Pericranium
• Pitfalls
• Bleeding from Scalp laceration will result in
  shock ( especialling in children )

6
Anatomy Physiology

• Brain
• Cerebrum
• 1. Frontal emotion, motor function
  expression of speech ( motor speech areas )
• 2. Parietal sensory spatial orientation
• 3. Temperal memory function, responsible
  for speech
• 4. Occipital vision
• Brain Stem
• 1. Midbrain reticular activating system
• 2. Pons reticular activating system
• 3. Medulla cardiorespiratory center
• 4. Cerebellum coordiration balance

7
Anatomy Physiology

• Tentorium
• Supratentorial compartment ( anterior middle
  cranial fossa )
• Uncal herniation ( Supratentorial pressure )
  ipsilateral pupillary dilation contralateral
  hemiplegia
• Infratentorial compartment ( posterior fossa )

8
Anatomy Physiology

• Intracranial Pressure Hemostasis
• Kicp VCSF VBl VBr
• Pitfalls
• A normal intracranial pressure dose not
  necessarily exclude a mass lesion ( compensation
  stage )

9
Intracranial Pressure

• Pressure / Volume Curve
• ICP Herniation
• 10 point of decompensation
• volume of mass
• keep the patients pressure volume
• in the flat portion of the curve, rather
• than to treat the patient at the point of
• decompensation

10
Increased Intracranial Pressure( IICP )

• Result in
• Decreased cerebral perfusion pressure ( CPP )
• CPP Mean Arterial Blood Pressure-
• ICP
• Altered level of consciousness

11
Anatomy Physiology

• Autoregulation of Cerebral blood flow ( CBF )
• Noninjured person
• CBF is consiant between mean blood
• pressure of 50 and 160 mm Hg
• Head-injured patient
• autoregulation is often disturbed, so he
• vulnerable to secondary brain injury due
• to ischemia from hypotensive episode (
• keep vital signs is very important )

12
Classification of Head Injury

• Mechanism of injury
• Severity of injury
• Morphology of injury ( base on CT scan )

13
Classification of Head Injury

• Mechanism of injury
• Blunt
• automobile collision, fall assault
• Penetrating
• gunshot wounds, other penetrating
• injuries

14
Classification of Head Injury

• Severity
• Coma GCS sore lt 8
• Mild GCS score 14 15
• Moderate GCS score 9 13
• Severe GCS score 3 8

15
Classification of Head Injury

• Morphology of Injury
• Skull fractures
• Intracranial lesions

16
Skull fractures

• Vault
• linear / stellate,
• depressed / nondepressed,
• open / close
• Basilar (diagnosed by CT bone window)
• raccoon eyes, Battles signs
• (retroauricular ecchymosis),
• CSF leakage and 7th nerve palsy

17
Intracranial Lesions

• Focal lesions
• Diffuse lesions

18
Intracranial Lesions

• Focal lesions
• Epidural hematoma
• most due to tearing of the middle meningeal
  artery
• prognosis is usually excellent ( underlying brain
  injury is limited )
• CT biconvex or lenticular in shape
• Pitfalls classical lucid interval and talk and
  die

19
Intracranial Lesions

• Focal lesions
• Subdural hematoma
• brain damage much more prognosis is much worse
  than EDH
• tearing of a bridging vein

20
Intracranial Lesions

• Focal lesions
• Contusions and intracerebral hematomas
• most occur in the frontal temporal lobes
• always seen in association with SDH

21
Intracranial Lesions

• Diffuse injuries
• Mild concussion temporary neurologic
  dysfunction, confusion disorientation without
  or with amnesia
• Classic cerebral concussion
• 1.Transient reversible loss of consciousness,
  returns to full consciousness by 6 hrs.
• 2.No sequelae other than amnesia for the events
• 3.post-concussion syndrome memory difficulties,
  dizziness, nausea, anosmia depression

22
Intracranial Lesions

• Diffuse injuries
• Diffuse axonal injury ( DAI )
• 1.prolonged postraumatic coma that
• is not due to a mass lesion or
• ischemic insults
• 2.usually having decortication or
• decerebation posture
• 3.autonomic dysfunction
• hypertension, hyperhidrosis
• hyperpyrexia

23
Assessment of Head injury

• History
• Mechanism of injury
• Pre and post injury status
• Document / communicate
• Reassess

24
Assessment

• Vital Signs
• Identifies neurologic systemic status
• Presume hypotension due to hypovolemia, not head
  injury

25
Minineurologic Exam

• Purpose
• Determine severity of brain injury
• Detect deterioration
• Categories injuries

26
Minineurologic Exam

• Level of consciousness - GCS
• eye opening
• verbal
• motor
• Pupil
• Motor lateralization ( mass lesion )

27
Minineurologic Exam

• Pupils
• Equality
• Briskness of response
• Anormal gt1 mm difference in size

28
Minineurologic Exam

• Extremity Movement
• Equality
• Pain response
• Lateralized weakness - mass lesion

29
Minineurologic Exam

• Repeat compare
• Detect deterioration
• initiate treatment
• Neurosurgical Consultation

30
Minineurologic Exam

• Dont presume altered status due
• to alcohol / drugs ingestion

31
Diagnostic Procedure

• CT
• be obtained in all head -injury patients (
  ideally ), especially there is a history of more
  than a momentary loss of consciousness, amnesia
  or severe headaches
• C-Spine
• Alcohol level urine toxic screen
• Skull X-ray
• penetrating head injury or when CT scan is not
  immediately available

32
Head injury Management

• Management Goals
• Establish diagnosis
• Assure brain metabolism prevent secondary brain
  injury
• Consult Neurosurgen early or early transfer

33
Head injury Management

• Management of Mild head injury
• Normal CT
• 1. Brought back to ER if need ( Head- injury
  warning discharge instructions )
• 2. No companion gt Admission or observe at ER
• Abnormal CT Admission

34
Head-injury Warning discharge Instruction

• Drowsiness or increasing difficulty in awaking
  patient ( Awaken patient every 2 hrs )
• Nausea or Vomiting
• Convulsion or fits
• Bleeding or Watery discharge from the nose or ear
• Severe headache
• Weakness or loss of feeling in the arm or leg
• Confusion or strange behavior
• One pupil larger than the other, double vision or
  visual disturbance
• Very slow or very rapid pulse, or an unusual
  breathing pattern

35
Head injury Management

• Management of Moderate Head Injury
• GCS 9 13
• All need brain CT
• All need to be admitted, even if CT scan is normal

36
Head injury Management

• Management of Severe Head Injury
• GCS 3 8
• Prompt diagnosis treatment is of utmost import
  ( wait and see disastrous )
• Primary survey Cardiopulmonary stabilization be
  achieved rapidly
• Secondary survey gt 50 had additional major
  systemic injury
• Minineurologic Examination reliable
  minineurologic examination prior to sedating or
  paralying the patient

37
Medical Therapies for Head Injury

• Goal
• To prevent secondary damage to an already
  injuried brain

38
Medical Therapies for Head Injury

• Intravenous Fluid
• 1. Keep euvolemic status, dehydration is
  more harmful ( vital signs stable )
• 2. Not to use hypotonic or glucose-containing
  fluids
• Hyperventilation
• 1. Keep PaCO2 at 2530 mmHg when the presence
  of raised ICP
• 2. PaCO2 lt 25 mmHg is avoided ( vasoconstriction
  gt CBF )

39
Medical Therapies for Head Injury

• Mannitol
• Indication
• 1. Comatous patient who initially has
  normal, reactive pupils, but the develops
  pupillary dilatation with or without
  hemiparesis
• 2. Patient with bilaterally dilated and
  nonreactive pupils who are not hypotensive
• Dose ( bolus ) 1 g/Kg
• Lasix Be used in consultation with a
  neurosurgeon

40
Medical Therapies for Head Injury

• Steroid
• Not demonstrated any beneficial effect
• Anticonvulsants
• High incidence of Late epilepsy
• 1. Early seizure occurring within the first week
• 2. An intracranial hematoma
• 3. Depressed skull fracture
• phenytoin reduce the incidence of seizure in the
  first week of injury but not thereafter

41
Restlessness

• Identify etiology
• Pain
• Hypoxia or shock
• Correct cause
• Analgesics / Sedatives
• Ventilation / Treat shock

42
Summary

• In a comatose patient, secure maintain airway (
  endotracheal intubation )
• Moderately hyperventilation, keep PaCO2 at 2535
  mmHg
• Treat shock aggressively
• Resuscitate with normal saline or Ringers
  lactate ( avoid hypotonic or glucose-containing
  fluid )
• keep euvolemic status

43
Summary

• Avoid the use of long-acting paralytic agents
• Perform a minineurologic examination after
  stabilizing the blood pressure and before
  paralying the patient
• Exclude cervical spine injury
• Contact a neurosurgeon as early as possible
• Frequently reassess the patients neurologic
  status