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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

(Paco₂ 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
 Cushing’s 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 : PaCO₂ 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 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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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