ATLS - Head Trauma modified

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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
Cushing’s
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 = 14–15

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 = 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
©ACS
Severe Brain Injury

GCS Score = 3–8

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?
©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
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