Committee on Trauma Presents

Head
Trauma

ACS
 Objectives

Describe basic intracranial physiology.

Recognize the importance of limiting
secondary brain injury.
Perform a focused neurologic exam.
Stabilize and arrange for definitive care.

ACS
 Anatomy and physiology effects?

Rigid, nonexpansile skull filled with

brain, CSF, and blood
CBF autoregulation
Autoregulatory compensation
disrupted by brain injury
Mass effect of intracranial hemorrhage
ACS
 Monro-Kellie Doctrine
Venous Art. Brain CSF
Volume Vol.

Ven. Art.
Brain Mass CSF
Vol. Vol.

75 mL Arterial 75 mL
Brain Mass CSF
Volume

ACS
Volume Pressure Curve

60- Herniation
55- ICP
50- (mm Hg)
45-
40-
35- Point of
30- Decompensation
25-
20-
15-
10-
5- Compensation
Volume of Mass
ACS
 Intracranial Pressure (ICP)

10 mm Hg = Normal
> 20 mm Hg = Abnormal
> 40 mm Hg = Severe
Many pathologic processes affect outcome
Sustained ICP leads to brain function and
outcome

ACS
Cerebral Perfusion Pressure*

MBP ICP = CPP

Normal 90 10 80
Cushings
Response 100 20 80

Hypotension 50 20 30

* CPP Cerebral Blood Flow

ACS
 Autoregulation

If autoregulation is intact, CBF is

maintained with a mean BP of 50 to
160 mm Hg.
Moderate or severe brain injury:
Autoregulation often impaired
Brain more vulnerable to episodes of
hypotension secondary brain injury
ACS
 Mild Brain Injury

GCS Score = 1415 X-rays as indicated

History Alcohol / drug
Exclude systemic screens as indicated
injuries Liberal use of head
Neurologic exam CT

Observe or discharge based on findings

ACS
 Moderate Brain Injury
Admit and observe
GCS Score = 913

Frequent neurologic exams

Repeat CT scan

Initial evaluation
same as for mild
injury
CT scan for all
Deterioration:
Manage as severe
head injury
ACS
 Severe Brain Injury

GCS Score = 38
Evaluate and resuscitate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Identify associated injuries
ACS
 Classifications of Brain Injury

By Morphology: Brain
Epidural (extradural)
Focal Subdural
Intracerebral

Concussion
Diffuse Multiple contusions
Hypoxic / ischemic injury
ACS
 Diffuse Brain Injury

Mild concussion Severe, ischemic

insult

Normal CT Diffuse Injury ACS

 Contusion / Hematoma

Coup / contracoup injuries

Most common: Frontal / temporal lobes
CT changes usually progressive
Most conscious patients: No operation

ACS
Contusion / Hematoma

Large frontal
contusion with
shift

ACS
 Epidural Hematoma

Associated with skull fracture

Classic: Middle meningeal artery tear
Lenticular / biconvex
Lucid interval
Can be rapidly fatal
Early evacuation essential
ACS
Epidural Hematoma
Temporal
Epidural
Hematoma

Uncal
herniation

ACS
 Subdural Hematoma

Venous tear / brain laceration

Covers cerebral surface
Morbidity / mortality due to underlying
brain injury
Rapid surgical evacuation
recommended, especially if > 5 mm shift
of midline
ACS
Subdural Hematoma

ACS
 Priorities

ABCDE
Minimize secondary brain injury
Administer O2
Maintain blood pressure
(systolic > 90 mm Hg)

ACS
 Focused Neurologic Exam?

GCS Score
Pupils
Lateralizing signs

Consult neurosurgeon early

ACS
Indications for CT Scan?

All patients with

suspicion of brain
injury

ACS
 Medical Management

Intravenous fluids
Euvolemia
Isotonic
Controlled ventilation
Goal: Paco2 at 35 mm Hg

ACS
 Medical Management

Mannitol
Use with signs of tentorial herniation
Dose: 1.0 g / kg IV bolus
Consult with neurosurgeon first

ACS
 Medical Management

Other medications
Anticonvulsants
Sedation
Paralytics

ACS
 Surgical Management

Scalp Injuries
Possible site of major blood loss
Direct pressure to control bleeding
Occasional temporary closure

ACS
 Surgical Management

Intracranial Mass Lesion

May be life-threatening if expanding
rapidly
Immediate neurosurgical consult
Hyperventilation / Mannitol
Damage control craniotomy: Transfer
to neurosurgeon (rural / austere areas)
ACS
ACS
 Summary: What should I do?

Maintain mean BP > 90 mm Hg

Maintain Paco2 near / at 35 mm Hg
Use isotonic solution for euvolemia
Frequent neurologic exams
Liberal use of CT scans
Early neurosurgical consult
ACS
 Summary: What should I not do?

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
ACS