Head Trauma

Common major trauma

4 million people experience head
trauma annually
Severe head injury is most frequent cause of trauma
death
GSW to cranium: 75-80% mortality
At Risk population
Males 15-24
Infants
Young Children
Elderly
Introduction to Head
Injuries
TIME IS CRITICAL
Intracranial Hemorrhage
Progressing Edema
Increased ICP
Cerebral Hypoxia
Permanent Damage

Severity is difficult to recognize
Subtle signs
Improve differential diagnosis
Improves survivability
Introduction to Head
Injuries
Mechanism of Injury
Blunt Injury
Motor vehicle collisions
Assaults
Falls
Penetrating Injury
Gunshot wounds
Stabbing
Explosions

Pathophysiology of
Head Injury
Different Types of Injury
Head Injury
Cranial Injury
Brain Injury
Head Trauma
Open
Skull compromised
and brain exposed

Closed
Skull not compromised
and brain not exposed
6 Head Trauma -
Scalp Injury
Contusions
Lacerations
Avulsions
Significant Hemorrhage

ALWAYS Reconsider MOI for severe
underlying problems
Head Injuries
Scalp wound
Highly vascular, bleeds briskly
Shock: child may develop
Shock: adult another cause
Management
No unstable fracture:
direct pressure, dressings
Unstable fracture: dressings, avoid
direct pressure
8 Head Trauma -
Skull fracture
Linear nondisplaced
Depressed
Compound
Suspect fracture
Large contusion or darkened swelling
Management
Dressing, avoid excess pressure
Head Injuries
9 Head Trauma -
Cranial Injury
Trauma must be extreme to fracture
Linear
Depressed
Open
Impaled Object

Basal Skull
Unprotected
Spaces weaken
structure
Relatively
easier to fracture

Cranial Injury
Basal Skull Fracture
Signs
Battles Signs
Retroauricular Ecchymosis
Associated with fracture of
auditory canal and lower
areas of skull
Raccoon Eyes
Bilateral Periorbital
Ecchymosis
Associated with orbital
fractures
Basilar Skull Fracture
Battles sign Raccoon eyes
13 Head Trauma -
Cranial Injury
Basilar Skull
Fracture
May tear dura
Permit CSF to drain
through an external
passageway
May mediate rise of ICP
Evaluate for Target or
Halo sign
Crainial Injuries
Penetrating trauma
15 Head Trauma -
Bullet fragments
Head Trauma - 16
Forces that cause skull fracture
can also cause brain injury.
Brain Injury
As defined by the National Head
Injury Foundation
a traumatic insult to the brain capable of
producing physical, intellectual, emotional,
social and vocational changes.
Brain Injury
Response to injury
Swelling of brain
Vasodilatation with increased blood volume
Increased ICP
Decreased blood flow to brain
Perfusion decreases
Cerebral ischemia (hypoxia)


18 Head Trauma -
Altered Mental
Status
Altered orientation
Alteration in
personality
Amnesia
Retrograde
Antegrade
Cushings Reflex
Increased BP
Bradycardia
Erratic respirations
Signs & Symptoms
of Brain Injury
Vomiting
Without nausea
Projectile
Body temperature
changes
Changes in pupil
reactivity
Decorticate
posturing
Pathophysiology of Changes
Frontal Lobe Injury
Alterations in personality
Occipital Lobe Injury
Visual disturbances
Cortical Disruption
Reduce mental status or Amnesia
Retrograde
Unable to recall events before injury
Antegrade
Unable to recall events after trauma
Repetitive Questioning
Focal Deficits
Hemiplegia, Weakness or Seizures
Signs & Symptoms
of Brain Injury
Classification
Direct
Primary injury caused by forces of trauma
Indirect
Secondary injury caused by factors resulting
from the primary injury

Brain Injury
Direct brain injury
Immediate damage
due to force
Coup and contracoup
Fixed at time of injury
Management
Directed at prevention
22 Head Trauma -
Direct Brain Injury Types
Coup
Injury at site of
impact
Contrecoup
Injury on
opposite side
from impact
Brain Injury
Indirect brain injury
Results from hypoxia
or decreased perfusion
Response to primary injury
Develops over hours
Management
Good prehospital care can help prevent
24 Head Trauma -
Direct Brain Injury Categories
Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury
Focal Brain Injury
Cerebral Contusion
Blunt trauma to local brain tissue
Capillary bleeding into brain tissue
Common with blunt head trauma
Confusion
Neurologic deficit
Personality changes
Vision changes
Speech changes
Results from
Coup-contrecoup injury
Brain Injuries
Cerebral contusion
Bruising of brain tissue
Swelling may be rapid and severe
Level of consciousness
Prolonged unconsciousness,
profound confusion or amnesia
Associated symptoms
Focal neurological signs
May have personality changes
27 Head Trauma -
Epidural Hematoma
Bleeding between dura
mater and skull
Involves arteries
Middle meningeal artery
most common
Rapid bleeding &
reduction of oxygen to
tissues
Herniates brain toward
foramen magnum
Focal Brain Injury
Intracranial Hemorrhage
Intracranial Hemorrhage
Acute epidural hematoma
Arterial bleed
Temporal fracture common
Onset: minutes to hours
Level of consciousness
Initial loss of consciousness
Lucid interval follows
Associated symptoms
Ipsilateral dilated fixed pupil, signs of increasing ICP,
unconsciousness, contralateral paralysis, death
29 Head Trauma -
Subdural Hematoma
Bleeding within meninges
Beneath dura mater & within
subarachnoid space
Above pia mater
Slow bleeding
Superior sagital sinus
Signs progress over several
days
Slow deterioration of
mentation
Focal Brain Injury
Intracranial Hemorrhage
Intracranial Hemorrhage
Acute subdural hematoma
Venous bleed
Onset: hours to days
Level of consciousness
Fluctuations
Associated symptoms
Headache
Focal neurologic signs
High-risk
Alcoholics, elderly, taking anticoagulants
31 Head Trauma -
Intracranial Hemorrhage
Intracerebral hemorrhage
Arterial or venous
Surgery is often not helpful
Level of consciousness
Alterations common
Associated symptoms
Varies with region and degree
Pattern similar to stroke
Headache and vomiting

32 Head Trauma -
Intracerebral Hemorrhage
Rupture blood vessel within the brain
Presentation similar to stroke symptoms
Signs and symptoms worsen over time
Focal Brain Injury
Intracranial Hemorrhage
Diffuse Brain Injury
Due to stretching forces placed on
individual nerve cells
Pathology distributed throughout
brain
Types
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury
Mild to moderate form of Diffuse Axonal
Injury (DAI)
Nerve dysfunction without anatomic damage
Transient episode of
Confusion, Disorientation, Event amnesia
Suspect if patient has a momentary loss
of consciousness
Management
Frequent reassessment of mentation
ABCs
Diffuse Brain Injury
Concussion
Brain Injuries
Concussion
No structural injury to brain
Level of consciousness
Variable period of unconsciousness or confusion
Followed by return to normal consciousness
Retrograde short-term amnesia
May repeat questions over and over
Associated symptoms
Dizziness, headache, ringing in ears, and/or nausea
36 Head Trauma -
Classic Concussion
Same mechanism as concussion
Additional: Minute bruising of brain tissue
Unconsciousness
May exist with a basilar skull fracture
Signs & Symptoms
Unconsciousness or Persistent confusion
Loss of concentration, disorientation
Retrograde & Antegrade amnesia
Visual and sensory disturbances
Mood or Personality changes
Diffuse Brain Injury
Moderate Diffuse Axonal Injury
Brain Injuries
Diffuse axonal injury
Diffuse injury
Generalized edema
No structural lesion
Most common injury from
severe blunt head trauma
Associated symptoms
Unconscious
No focal deficits
38 Head Trauma -
Brainstem Injury
Significant mechanical disruption of
nerve cells
Cerebral hemispheres and brainstem
High mortality rate
Signs & Symptoms
Prolonged unconsciousness
Cushings reflex
Decorticate or Decerebrate posturing
Diffuse Brain Injury
Severe Diffuse Axonal Injury
Brain Anatomy
40 Head Trauma -
Intracranial volume
Brain
CSF
Blood vessel volume
Dilatation with high pCO
2

Constriction with low pCO
2

Slight effect on volume
Intracranial Perfusion
Cranial volume fixed
80% = Cerebrum, cerebellum & brainstem
12% = Blood vessels & blood
8% = CSF
Increase in size of one component diminishes
size of another
Inability to adjust = increased ICP
Intracranial Perfusion
Compensating for Pressure
Compress venous blood vessels
Reduction in free CSF
Pushed into spinal cord
Decompensating for Pressure
Increase in ICP
Rise in systemic BP to perfuse brain
Further increase of ICP
ICP BP
Factors Affecting ICP
Vasculature Constriction
Cerebral Edema
Systolic Blood Pressure
Low BP = Poor Cerebral Perfusion
High BP = Increased ICP
Carbon Dioxide
Reduced respiratory efficiency
Intracranial Pressure
Role of Carbon Dioxide
Increase of CO2 in CSF
Cerebral Vasodilation
Encourage blood flow
Reduce hypercarbia
Reduce hypoxia
Contributes to ICP
Reduced levels of CO2 in CSF
Cerebral vasoconstriction
Results in cerebral anoxia
Increased pressure
Compresses brain tissue

Herniates brainstem
Compromises blood supply
Signs & Symptoms
Upper Brainstem
Vomiting
Altered mental status
Pupillary dilation
Medulla Oblongata
Respiratory
Cardiovascular
Blood Pressure disturbances
Pressure & Structural
Displacement
Upper Brainstem Compression
Increasing blood pressure
Reflex bradycardia
Vagus nerve stimulation
Cheyne-Stokes respirations
Pupils become small and reactive
Decorticate posturing
Neural pathway disruption
Signs & Symptoms of Brain Injury
Physiological Changes
Middle Brainstem Compression
Widening pulse pressure
Increasing bradycardia
CNS Hyperventilation
Deep and Rapid
Bilateral pupil sluggishness or inactivity
Decerebrate posturing
Signs & Symptoms of Brain Injury
Physiological Changes
Lower Brainstem Injury
Pupils dilated and unreactive
Ataxic respirations
Erratic with no pattern
Irregular and erratic pulse rate
ECG Changes
Hypotension
Loss of response to painful stimuli

Signs & Symptoms of Brain Injury
Physiological Changes
Physiological Issues
Indicate pressure on
CN-III (Oculomotor Nerve)
Pressure on nerve causes eyes to be sluggish, then
dilated, and finally fixed
Reduced peripheral blood flow
Pupil Size & Reactivity
Reduced Pupillary Responsiveness
Depressant drugs or Cerebral Hypoxia
Fixed & Dilated
Extreme Hypoxia
Signs & Symptoms of Brain Injury
Eye Signs
Head Trauma Assessment
ITLS Initial Assessment
Rapid Trauma Exam
Limit patient agitation, straining
Contributes to elevated ICP
Airway
Vomiting very common within first hour
Endotracheal intubation
51 Head Trauma -
Head Trauma - 52
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.
Reactive: ICP increasing
Nonreactive (altered LOC):
increased ICP
Nonreactive (normal LOC): not
from head injury
Pupils
Both dilated
Nonreactive: brainstem
Reactive: often reversible
Unilaterally dilated
53 Head Trauma -
Eyelid closure
Slow: cranial nerve III
Fluttering: often hysteria
Anisocoria
Glasgow Coma Scale
Suspect severe brain injury
GCS <9
54 Head Trauma -
*Decorticate posturing to pain
**Decerebrate posturing to pain
Extremity Posturing
Decorticate
Arms flexed
and legs extended
Decerebrate
Arms extended
and legs extended

55 Head Trauma -
Increasing ICP


56 Head Trauma -
Vital Sign Change with Increasing ICP
Respiration Increase, decrease, irregular
Pulse Decrease
BP Increase, widening pulse
pressure
Cushings response
As ICP increases, systolic BP increases
As systolic BP increases, pulse rate decreases
Head Trauma - 57
Early efforts
to maintain brain perfusion
can be life-saving.
The Injured Brain
Hypoxia
Perfusion decrease causes cerebral ischemia
Hyperventilation increases hypoxia
significantly more than it decreases ICP
Assist ventilation
High-flow oxygen
One breath every 68 seconds
SpO
2
>95%
Maintain EtCO
2
at 35 mmHg
58 Head Trauma -
The Injured Brain
59 Head Trauma -
Hypotension
Single instance increases mortality
Adult (systolic <90 mmHg) 150%
Child (systolic < age appropriate) worse
Fluid administration for traumatic
brain injury, GCS <9
Titrate to 110120 mmHg systolic
with or without penetrating hemorrhage
to maintain CPP
The Injured Brain
Cerebral herniation syndrome
Brain forced downward
CSF flow obstructed, pressure on brainstem
Level of consciousness
Decreasing, rapid progression to coma
Associated symptoms
Ipsilateral pupil dilatation, out-downward deviation
Contralateral paralysis or decerebrate posturing
Respiratory arrest, death
60 Head Trauma -
Cerebral Herniation
61
Is ICP severe enough
to outweigh cerebral ischemia?
Head Trauma -
Hyperventilation
Cerebral herniation syndrome
Herniation danger outweighs hypoxia
Indications for hyperventilation
TBI GCS <9 with decerebrate posturing
TBI GCS <9 with dilated or nonreactive pupils
TBI initial GCS <9, then drops >2 points
If signs resolve, stop hyperventilation.
62 Head Trauma -
Hyperventilation Rates




Capnography
Maintain EtCO
2
<30 mmHg, but >25 mmHg
63 Head Trauma -
Age Group Normal Rate Hyperventilatio
n
Adult 810 per minute 20 per minute
Children 15 per minute 25 per minute
Infants 20 per minute 30 per minute
Advanced Providers
Hypertonic Saline
Indication and Use
Movement of Particles vs
Movement of Water

Diffusion
Movement of particles from an area
of high concentration to an area of
low concentration.
Moves along normal
concentration gradient.
Passive
Slow
Movement of Water
Semi-permeable membrane


Popcorn and Beer Rule
Where ever the salt
goes, the water goes.
Movement of Water
Osmosis Movement of water
across a semi-permeable
membrane from an area of low
particle concentration to an area
of high particle concentration
(dilute to concentrated)
Osmotic Pressure
The force that moves water across
a semi-permeable membrane

Some energy required

Fast process
Movement of Water:
Capillaries

Hydrostatic Pressure

Colloid Osmotic Pressure

Net Filtration
Hydrostatic Pressure
Blood pressure PUSHES water out
of the capillaries (filtration)
Colloid Osmotic
Pressure (Onconic
Pressure)

Plasma proteins (colloids) exert a
PULL on water to keep it in the
capillary
Net Filtration
Hydrostatic pressure forcing out

Osmotic pressure pulling in

Should be equal

Hydrostatic Osmotic = Zero


Edema
Accumulated water in interstitial
space
Decrease plasma proteins (colloids)
Increased hydrostatic pressure
Increased capillary permeability
Blocked drainage
Concentration of
fluids

Tonicity
Isotonic concentration equal to
the concentration of surrounding
spaces; stays in the veins
i.e. blood
0.9% saline (normal saline)
Lactated Ringers Solution
Hypotonic concentration less
than the concentration of
surrounding spaces; water goes
into the interstitial spaces
Fresh water
5% dextrose in water
0.45% saline
5% D/.2 saline

Hypertonic concentration
greater than the concentration of
surrounding spaces; pulls water
from the interstitial spaces
Protein solutions
Lipid solutions
10% fructose
50% mannitol
3.3% saline
Management of Increased ICP
Hypertonic Solutions to pull water
from the swollen brain
5 cc/kg 3.3% saline
Caution with packaging
Review
Answer the following questions as a group.
If doing this CE individually, please e-mail your
answers to:
shelley.peelman@presencehealth.org
Use Apr 2013 CE in subject box.
You will receive an e-mail confirmation. Print
this confirmation for your records, and
document the CE in your PREMSS CE record
book.
IDPH site code 06-7100-E-1213
82 Head Trauma -
Review
1. What type of head injury is the
man in the previous slide
demonstrating?
2. What 2 assessment findings
confirm this injury?
3. What is the most important initial
treatment for this man?


Review
Your patient has been involved in a
motorcycle accident. He was not
wearing a helmet. You find him
unconscious, airway open and
breathing 4 times per minute. His
blood pressure is 180/100, pulse 64.
Review
4. What complication of brain injury
do his vital signs suggest?
5. When you check this patients
pupils what would you expect to
find?
6. How would you treat this patient?
Review
7. What type of brain injury is
caused from arterial bleeding?
8. Describe the typical changes in
level of consciousness in this
type of injury.

Review
A patient is unconscious, does not
open her eyes, does not make any
sounds and has no motor
response to stimulation.
9. What is her Glasgow Coma
Scale?
Review
A patient is confused, opens his
eyes to verbal stimulus and can
follow simple commands.
10. What is his Glasgow Coma
Scale?
Review
Advanced Providers Only
Your patient has been involved in a
motorcycle accident. He was not
wearing a helmet. You find him
unconscious, snoring respirations at
a rate of 4 times per minute. His
blood pressure is 180/100, pulse 50.
You also observe decorticate
posturing.

Review
11. How will you manage this patients
airway?
12. How many breaths per minute should
this patient receive?
13. What is this patients Glasgow Coma
Scale?
14. What further treatment is needed to
manage this patient?
15. What will the treatment in question 14
do for this patients injury?
Answers
1. Basilar skull fracture
2. Raccoon eyes, blood/CSF leaking from
nose
3. Open the airway and apply high flow
oxygen
4. Increased intracranial pressure
5. Small, reactive
6. Open the airway and hyperventilate at 20
breaths/min
Answers
7. Epidural hematoma
8. Initial loss of consciousness, lucid
interval followed by deteriorating level of
consciousness
9. 3
10. 13



Answers
11. Intubation
12. 20 breaths/min
13. 5
14. 3.3% hypertonic saline at 5 ml/kg over 30
minutes
15. Pulls water from swollen brain