ACS

Head Trauma
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Objectives
Describe basic intracranial physiology.
Evaluate the head / brain-injured patien.
Perform necessary stabilization procuderes.
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)

10mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe
Many pathologic processes affect outcome
ICP Brain function,outcome
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Autoregulation
CFB maintned with X 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 : Retroaucricular
anterior skull base ecchymosis
CSF otorhea : Mid Facial nerve injury
skull base Loss of hearing
Hemotympanum Pneumocephalus
Periorbital
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 rafidly fatal
Early evacuation pragnosis
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
Rpid 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
Sequalae 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 screen 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/resusciate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Indentify associated injuries
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Severe Brain injury

Airway / Breathing
Airway protection

Supplemental oxygen

Assisted ventilation if necessary

(Paco 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 quikly

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 resusciation
Frequently
Document changes

Consult neusurgeon 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

Hermation
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 : PaCO 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 PaCO 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 (Don,t)

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