PTCPTC

HEAD TRAUMAHEAD TRAUMA

By

Dr. Vashdev

FCPS ,

Consultant Neuro and Spinal Surgeon &

DEPARTMENT OF NEUROSURGERY

LIAQUAT UNIVERSITY OF MEDICAL AND HEALTH SCIENCES.

JAMSHORO

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Head TraumaHead Trauma

Objectives• To understand the structured approach

to the patient with head trauma• To learn how to identify serious and life-

threatening head injuries

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Head TraumaHead Trauma

• 1/3-1/2 of trauma deaths• Good outcomes possible without

CT scans and neurosurgeons• Aim to avoid secondary brain injury• Hypoxia and hypotension double

mortality

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Head TraumaHead TraumaApproachApproach

Airway

Breathing

Circulation

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Head TraumaHead TraumaPhysiologyPhysiology

CPP = MAP - ICP

CPP = cerebral perfusion pressureMAP = mean arterial pressure

ICP = intracranial pressure

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Cerebral Blood FlowCerebral Blood FlowDepends on:Depends on:

• CPP (MAP-ICP)

• PaCO2

• PaO2

• Local metabolites

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Head TraumaPathophysiology

• Primary Injury

• occurs at time of injury

• Secondary Injury

• occurs after injury

• may be preventable

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Head TraumaPrimary injury

Diffuse axonal injury Acceleration deceleration

Cerebral contusion Penetrating injury

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Head Trauma Secondary injury

Hypoxia Hypoperfusion (↑ ICP, ↓ MAP) Hypoglycaemia Hyperthermia (fever) Seizures

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Head TraumaHead TraumaInitial assessmentInitial assessment

Airway (+ C-spine)

Breathing

Circulation

Disability ( pupils)

Exposure

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Head TraumaHead TraumaExaminationExamination

• Glasgow Coma Score• Pupils• Corneal reflex• Eye position • Fundi

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Head TraumaHead TraumaExaminationExamination

• Tympanic membrane• Scalp and skull

(Raccoon eyes, Battle sign)• Respiratory Pattern• Muscle tone• Posture• Tendon reflexes

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Head Trauma Head Trauma GCS Eye openingGCS Eye opening

Open spontaneously 4

Open to command 3

Open to pain 2

None 1

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Head Trauma Head Trauma GCS Best Verbal Response GCS Best Verbal Response

Oriented 5

Confused 4

Inappropriate words 3

Inappropriate sounds 2

None 1

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Head TraumaHead TraumaGCS Best Motor ResponseGCS Best Motor Response

Obeys command 6Localises to pain 5Withdraws to pain 4Abnormal flexion 3Extensor response 2None 1

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Head Trauma Head Trauma Severity of Head InjurySeverity of Head Injury

Severe GCS <8

Moderate GCS 9-12

Mild GCS 13-15

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Head Trauma Head Trauma Pupillary signsPupillary signs

• Size• Reactivity• Equality

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Head Trauma Head Trauma Pupillary responsesPupillary responses

Fixed, dilated,

unresponsive

• Severe hypoxia• Severe brain Injury• Hypothermia• Seizures

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Head Trauma Head Trauma Pupillary responsesPupillary responses

Unilateral, dilated,

unresponsive

• Expanding lesion on same side

• Tentorial herniation

• Seizures

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Head TraumaHead TraumaAcute extradural or subduralAcute extradural or subdural

• Potentially life-threatening• Immediate recognition essential• Require burr-hole decompression

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Head TraumaHead TraumaAcute extraduralAcute extradural

• LOC → lucid interval → deterioration• Middle meningeal artery bleed• Overlying skull fracture• Contralateral hemiparesis• Fixed pupil on side of injury

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Head TraumaHead TraumaAcute subduralAcute subdural

• Tearing of bridging vein between cortex and dura

• Underlying brain injury• Usually no lucid interval• Worse prognosis than extradural

haematoma

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Head TraumaHead TraumaOther injuriesOther injuries

• Base-of-skull fractures• Cerebral concussion• Depressed skull fracture• Intracerebral haematoma

Usually do not require urgent neurosurgery consultation

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AirwayBreathing (ventilation)Circulation + Avoid ↑ ICP

Aim to prevent secondary injury

Head TraumaHead TraumaManagementManagement

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Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)

• Intubate• Normal CO2

• Treat hypotension with fluid • Sedation +/- paralysis

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Head TraumaHead TraumaSevere (GCS<8)Severe (GCS<8)

• Nurse head up 20o

• Prevent hyperthermia• Complete secondary survey• Reassess frequently

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FINDINGS WITH LOW FINDINGS WITH LOW RISK OF ICIRISK OF ICI- asymptomatic

- headache- dizzines- scalp hematoma- skull x-ray normal- DISCHARGE on instructions- change in level of consiousness- severe headache- persistent vomiting- bradycardia

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FINDINGS WITH FINDINGS WITH MODERATE RISK ICI MODERATE RISK ICI

h/o loss of cons. progressing headache post traumatic seizures age <2 years post traumatic amnesia vomiting signs of BSF multiple trauma severe facial injuries

CRITERIA FOR OBSERVATION AT HOME

normal C.T scan GCS - >14 reasonable access to hospital

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FINDING WITH HIGH RISK FINDING WITH HIGH RISK OF ICIOF ICI

- Depressed level of Con.

- Focal Neurologic Findings

- Penetrating skull injuries

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Head TraumaHead TraumaBewareBeware

• Deteriorating conscious state• Penetrating injury• Focal neurological signs

- unequal, dilated pupils

- seizures

- posturing

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Head TraumaHead Trauma

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Head TraumaHead Trauma

Summary• ABCs• Prevent secondary injury• Isolated head trauma doesn’t cause

hypotension • Look for other injuries• Deterioration → reassess

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