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ACS

Head Trauma

ACS

Objectives

Describe basic intracranial physiology.

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

ACS

Head Injury

Common problem
High morbidity and mortality
Secondary insults
Worsen outcome
Often preventable

Early neurosurgical consult and transfer

ACS

Neurosurgeon Needs to Know

Age and history

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

ACS

Intracranial Pressure (ICP)

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

ACS

ACS

ACS

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
< 25mL/100 g/min
5 mL/100 g/min

Normal
EEG activity
Cell death

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Classifications of Head injury

Blunt
By
Mechanism
Penetrating

Mild
By
Severity

Moderate
Severe

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

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Classification of head injury

ACS

By Morphology
Vault
Skull
Fracture
Basilar

Linear vs stellate
Depressed/ nondepressed
Open
With / without CSF leak
With / without cranial
palsy

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ACS

Basal Skull Fracture

CSF rhinorrhea :
anterior skull base
CSF otorrhea : Mid
skull base
Hemotympanum
Periorbital
ecchymosis

Retroauricular
ecchymosis
Facial nerve
injury
Loss of hearing
Pneumocephalus

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ACS

Classifications of Head Injury

By Morphology
Focal Injury

Diffuse Injury

Epidural
Subdural
Intracerebral
Mild concussion
Classic concussion
Diffuse axonal injury

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ACS

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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ACS

Epidural Hematoma

Can be rapidly fatal

Early evacuation prognosis
Venous epidurals : Possible nonsurgical
management

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ACS

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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ACS

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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ACS

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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ACS

Diffuse Axonal Injury

Prolonged deep coma (not due to mass

lesion)
Diffuse brain injury
Motor posturing
Frequent autonomic dysfunction

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ACS

Mild Brain Injury

GCS Score = 14-15

History
Exclude systemic
injuries
Neurologic exam

X-ray as indicated
Alcohol / drug
screens as indicated
Liberal use of head
CT

Observe or discharge based on findings

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ACS

Moderate Brain Injury

GCS Score = 9-13

Initial evaluation
same as for mild
injury
CT scan for all

Admit and observe

Frequent
neurologic exams
Repeat CT scan
Deterioration :
Manage as severe
head injury

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ACS

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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ACS

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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ACS

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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ACS

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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ACS

Severe Brain Injury

Disability

Minineurologic exam
On patient arrival
After resuscitation
Frequently
Document changes
Consult neurosurgeon early

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ACS

Severe Brain Injury

Cause

IIIrd Nerve compression

bilaterally
Inadequate CNS
perfusion
IIIrd nerve compression,
tentorial herniation
Optic nerve injury

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ACS

Severe Brain Injury

Cause

Drugs
Pontine lesion

Injured sympathetic
pathway

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ACS

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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ACS

Medical Management

Intravenous fluids
Euvolemia
Isotonic
Hyperventilation, if necessary
Goal : PaCO2 at 25-35 mm Hg

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ACS

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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ACS

Surgical Management
Scalp injuries

Possible site of major blood loss

Direct pressure to control bleeding
Occasional temporary closure

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ACS

Surgical Management
Intracranial Mass Lesion

May be life threatening if expanding

rapidly
Immediate neurosurgical consult
Hyperventilation / Mannitol
? Emergency burr holes ?

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ACS

Question

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ACS

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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ACS

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