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
Volume

Ven.
Vol.

75 mL

Art.
Vol.

Arterial
Volume

Art.
Vol.

Brain

Brain

Brain

CSF

Mass

Mass

CSF

CSF

75 mL

ACS

Volume Pressure Curve

60555045403530252015105-

Herniation

ICP
(mm Hg)

Point of
Decompensation

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

Exclude systemic
injuries

Alcohol / drug
screens as indicated

Liberal use of head

CT

Neurologic exam

Observe or discharge based on findings

ACS

Moderate Brain Injury

GCS Score = 913

Admit and observe

Initial evaluation
same as for mild
injury

Frequent neurologic exams

Repeat CT scan

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

Focal

Subdural
Intracerebral

Diffuse

Epidural (extradural)

Concussion

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