CHAPTER 6
HEAD TRAUMA
OBJECTIVES
 A.
Understand basic intracranial
anatomy & physiology
 B.
Evaluate a patient with a head injury
 C.
Perform the necessary stabilization
procedures
 D.
Determine the appropriate
disposition of the patient
Introduction





10 % of head injury die prior to reaching a
hospital
Head injury can be divided:
– mild ( 80 % )
– moderate (10 % )
– severe (10 % )
avoid secondary brain damage ( support vital
signs, avoid & treat IICP )
Obtaining a CT Scan should not delay patient
transfer ( transfer patient early )
Neurosurgical consult essential
Neurosurgen need know
1. Age of patient & the mechanism and time of
injury
2. Vital signs ( particular the blood pressure )
3. Results of minineurologic examination ( GCS
score; particular the motor response, and
pupillary reaction )
4. Associated injury
5. Results of the diagnostic studies ( CT scan )
Anatomy & Physiology

SCALP
– S: Skin
– C: Connective tissue
– A: Aponeurosis / galea aponeurotica
– L: Loose areolar tissue
– P: Pericranium
– Pitfalls
Bleeding from Scalp laceration will result in
shock ( especialling in children )
Anatomy & Physiology

Brain
– Cerebrum
1. Frontal: emotion, motor function &
expression of speech ( motor
speech areas )
2. Parietal: sensory & spatial orientation
3. Temperal: memory function, responsible
for speech
4. Occipital: vision
– Brain Stem
1. Midbrain: reticular activating system
2. Pons: reticular activating system
3. Medulla: cardiorespiratory center
4. Cerebellum: coordiration & balance
Anatomy & Physiology

Tentorium
–
Supratentorial compartment ( anterior &
middle cranial fossa )
»
–
Uncal herniation ( Supratentorial
pressure ): ipsilateral pupillary dilation
& contralateral hemiplegia
Infratentorial compartment ( posterior
fossa )
Anatomy & Physiology
 Intracranial
Kicp
Pressure: Hemostasis
VCSF + VBl + VBr
Pitfalls:
A normal intracranial pressure dose
not necessarily exclude a mass lesion
( compensation stage )
Intracranial Pressure
Pressure / Volume Curve
ICP
Herniation
10
point of decompensation
volume of mass
keep the patient’s pressure & volume
in the flat portion of the curve, rather
than to treat the patient at the point of
decompensation
Increased Intracranial Pressure( IICP )
Result in
–
Decreased cerebral perfusion
pressure ( CPP )
» CPP
: Mean Arterial Blood PressureICP
–
Altered level of consciousness
Anatomy & Physiology
Autoregulation of Cerebral blood flow ( CBF )

Noninjured person:
CBF is consiant between mean blood
pressure of 50 and 160 mm Hg

Head-injured patient:
autoregulation is often disturbed, so he
vulnerable to secondary brain injury due
to ischemia from hypotensive episode (
keep vital signs is very important )
Classification of Head Injury
 Mechanism
 Severity
of injury
of injury
 Morphology
of injury ( base on CT scan )
Classification of Head Injury
Mechanism of injury
–
Blunt:
automobile collision, fall & assault
–
Penetrating:
gunshot wounds, other penetrating
injuries
Classification of Head Injury
Severity
–
Coma:
GCS sore =< 8
–
Mild:
GCS score 14 ~ 15
–
Moderate: GCS score 9 ~13
–
Severe:
GCS score 3 ~ 8
Classification of Head Injury
Morphology of Injury
–
Skull fractures
–
Intracranial lesions
Skull fractures
 Vault:
linear / stellate,
depressed / nondepressed,
open / close
 Basilar (diagnosed by CT bone window):
raccoon eyes, Battle’s signs
(retroauricular ecchymosis),
CSF leakage and 7th nerve palsy
Intracranial Lesions
 Focal
lesions
 Diffuse lesions
Intracranial Lesions
Focal lesions:
 Epidural hematoma:
– most due to tearing of the middle
meningeal artery
– prognosis is usually excellent
( underlying brain injury is limited )
– CT: biconvex or lenticular in shape
– Pitfalls: classical lucid interval and
‘talk and die’
Intracranial Lesions
Focal lesions
 Subdural hematoma:
– brain damage much more & prognosis
is much worse than EDH
– tearing of a bridging vein
Intracranial Lesions
Focal lesions
 Contusions and intracerebral
hematomas:
– most occur in the frontal & temporal
lobes
– always seen in association with SDH
Intracranial Lesions
Diffuse injuries
– Mild concussion: temporary neurologic
dysfunction, confusion & disorientation
without or with amnesia
– Classic cerebral concussion:
1.Transient & reversible loss of
consciousness, returns to full
consciousness by 6 hrs.
2.No sequelae other than amnesia for the
events
3.post-concussion syndrome: memory
difficulties, dizziness, nausea, anosmia &
depression
Intracranial Lesions
Diffuse injuries:
– Diffuse axonal injury ( DAI )
1.prolonged postraumatic coma that
is not due to a mass lesion or
ischemic insults
2.usually having decortication or
decerebation posture
3.autonomic dysfunction:
hypertension, hyperhidrosis &
hyperpyrexia
Assessment of Head injury
History
 Mechanism of injury
 Pre and post injury status
 Document / communicate
 Reassess
Assessment
Vital Signs
 Identifies neurologic & systemic
status
 Presume hypotension due to
hypovolemia, not head injury
Minineurologic Exam
Purpose
 Determine severity of brain injury
 Detect deterioration
 Categories injuries
Minineurologic Exam
 Level
of consciousness - GCS
– eye opening
– verbal
– motor
 Pupil
 Motor lateralization ( mass lesion )
Minineurologic Exam
Pupils
 Equality
 Briskness of response
 Anormal: >1 mm difference in size
Minineurologic Exam
Extremity Movement
 Equality
 Pain response
 Lateralized weakness - mass lesion
Minineurologic Exam
 Repeat
& compare
 Detect deterioration
 initiate treatment
 Neurosurgical Consultation
Minineurologic Exam
Don’t presume altered status due
to alcohol / drugs ingestion
Diagnostic Procedure


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CT:
– be obtained in all head -injury patients
( ideally ), especially there is a history of
more than a momentary loss of
consciousness, amnesia or severe
headaches
C-Spine
Alcohol level & urine toxic screen
Skull X-ray:
– penetrating head injury or when CT scan is
not immediately available
Head injury Management
Management Goals
 Establish diagnosis
 Assure brain metabolism & prevent
secondary brain injury
 Consult Neurosurgen early or early
transfer
Head injury Management
Management of Mild head injury
 Normal CT :
1. Brought back to ER if need ( Headinjury warning discharge
instructions )
2. No companion ==> Admission or
observe at ER
 Abnormal CT : Admission
Head-injury Warning discharge
Instruction
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Drowsiness or increasing difficulty in awaking
patient ( Awaken patient every 2 hrs )
Nausea or Vomiting
Convulsion or fits
Bleeding or Watery discharge from the nose or
ear
Severe headache
Weakness or loss of feeling in the arm or leg
Confusion or strange behavior
One pupil larger than the other, double vision
or visual disturbance
Very slow or very rapid pulse, or an unusual
breathing pattern
Head injury Management
Management of Moderate Head Injury
 GCS 9 ~ 13
 All need brain CT
 All need to be admitted, even if CT scan
is normal
Head injury Management
Management of Severe Head Injury
 GCS 3 ~ 8
 Prompt diagnosis & treatment is of utmost
import ( wait and see = disastrous )
 Primary survey : Cardiopulmonary stabilization
be achieved rapidly
 Secondary survey : >= 50 % had additional
major systemic injury
 Minineurologic Examination : reliable
minineurologic examination prior to sedating
or paralying the patient
Medical Therapies for Head Injury
Goal:
To prevent secondary damage to
an already injuried brain
Medical Therapies for Head Injury


Intravenous Fluid:
– 1. Keep euvolemic status, dehydration is
more harmful ( vital signs stable )
– 2. Not to use hypotonic or glucosecontaining fluids
Hyperventilation:
– 1. Keep PaCO2 at 25~30 mmHg when the
presence of raised ICP
– 2. PaCO2 < 25 mmHg is avoided
( vasoconstriction ==> CBF )
Medical Therapies for Head Injury
Mannitol:
 Indication:
– 1. Comatous patient who initially has
normal, reactive pupils, but the develops
pupillary dilatation with or without
hemiparesis
– 2. Patient with bilaterally dilated and
nonreactive pupils who are not
hypotensive
 Dose ( bolus ) : 1 g/Kg
 Lasix : Be used in consultation with a
neurosurgeon
Medical Therapies for Head Injury


Steroid :
– Not demonstrated any beneficial effect
Anticonvulsants
– High incidence of Late epilepsy:
1. Early seizure occurring within the first
week
2. An intracranial hematoma
3. Depressed skull fracture
– phenytoin reduce the incidence of seizure in
the first week of injury but not thereafter
Restlessness

Identify etiology:
– Pain
– Hypoxia or shock

Correct cause:
– Analgesics / Sedatives
– Ventilation / Treat shock
Summary

In a comatose patient, secure & maintain
airway ( endotracheal intubation )

Moderately hyperventilation, keep PaCO2 at
25~35 mmHg

Treat shock aggressively

Resuscitate with normal saline or Ringer’s
lactate ( avoid hypotonic or glucose-containing
fluid )

keep euvolemic status
Summary

Avoid the use of long-acting paralytic agents

Perform a minineurologic examination after
stabilizing the blood pressure and before
paralying the patient

Exclude cervical spine injury

Contact a neurosurgeon as early as possible

Frequently reassess the patient’s neurologic
status