head injury

1. HEAD INJURY IN
THE ED
PRESENTED BY: Dr. Anjaly Mohan
MODERATOR: Dr. Pradeep Saxena
CHAIRPERSON: Dr. Adesh Shrivastava

2. “NO HEAD INJURY IS MINORTO BE NEGLECTED
NOR SERIOUS ENOUGHTO BE GIVEN UP”
-Hippocrates

3. • 25 year old man brought to you in the emergency
department close to midnight. He was riding a bike with no
helmet, that hit a tree, and he was thrown off the bike, 2
hours ago.
• When you receive, he is unconscious, reeks of alcohol and is
breathing heavily. He is profusely bleeding from a scalp
wound, and has a weak, thready pulse.

5. Anatomy Review
• Brain – cerebrum, brainstem, cerebellum
• Ventricular system – CSF filled spaces and aqueducts
• Blood in CSF – impairred absorption, raised ICP
• Edema and mass lesions – midline shift
• Intracranial compartments
• Tentorium cerebelli – supratentorial, infratentorial
• Tentorial hiatus/notch – midbrain (*uncal herniation)

6. Physiology Review
• Intracranial pressure –
• Normal – 10mm Hg
• Raised ICP – reduce cerebral perfusion – ischemia
• Monro –Kellie Doctrine
• Cerebral blood flow

7. Physiology Review
• Cerebral perfusion pressure (CPP) = MAP – ICP
• MAP of 50-150mm Hg – autoregulated to maintain BCF (pressure
autoregulation)
• Low MAP – infarction, ischemia
• High MAP – elevated ICP, swelling
• Chemical regulation – PaO2, PaCO2

9. HEAD INJURY
Any trauma to head other than superficial injuries to face NICE
• Suspected head injury???
• External signs of head or neck injury
• Bleeding from E – N –T
• Altered sensorium – confused, delerious, comatose
• Had a seizure or episode of LOC, vomiting
• Having symptoms or signs of neurological deficit

10. INITIALASSESSMENT
• ABCDE

12. Classification
• Severity
• Mild: GCS 13-15
• Moderate: GCS 9-12
• Severe: GCS 3-8 ATLS 10th Edition Student Manual
• Morphology

13. Skull fractures
• Cranial vault or skull base
• Linear or stellate
• Open or closed
• Basilar skull fracture
• Racoon eyes, battle sign, CSF rhinorrhea, otorrhea,VII andVIII palsy

14. Intracranial Lesions
Diffuse brain injuries
• Concussion – transient, nonfocal neurological disturbance; LOC
• Severe diffuse injuries
• CT – normal gray-white distinction absent
• Multiple punctate hemorrhages
• Shearing injuries – gray white border - DAI

15. Intracranial Lesions
Focal brain injuries
• Epidural hematomas –
• Biconvex or lenticular
• Temporal or temporoparietal
• Arterial; MMA
• Lucid interval
• Subdural hematoma
• Shearing of bridging veins
• Conforms to brain contours
• Concomitant parenchymal injury
• Contusions and intracerebral hematomas

16. “The primary goal of treatment for patients with
suspected traumatic brain injury is to prevent secondary
brain injury”

18. • Primary brain injury: occurs at time of trauma
• Secondary injury: develops subsequent to the initial injury
• The six – H:
• BP -Hypotension
• Temp -Hyperthermia/Hypothermia
• Electrolytes -Hyponatremia
• B Sugar -Hyperglycemia/Hypoglycemia
• ABG -Hypoxia, Hypercarbia

19. MANAGEMENT OF MILD BRAIN INJURY
13-15

21. Initial Management
• AMPLE history, neurological examination, anticoagulant use
• Mechanism, time of injury, initialGCS, confusion, amnestic
interval, seizure, headache severity
• Secondary survey – focused neurological examination
• Is CT required????

23. Admit if
• No CT available
• CT abnormal
• Skull fracture
• CSF leak
• Focal neurological deficit
• GCS does not return to 15 within 2 hours

24. Observation at home - criteria

25. Discharge Instructions

26. MODERATETRAUMATIC BRAIN INJURY
9-12

28. Initial management
• Primary survey and resuscitation
• Neurosurgery evaluation required
• Focused neurological exam
• Secondary survey andAMPLE history

29. Diagnosis and Secondary Management
• CT scan in all cases
• Look for other injuries
• Type and crossmatch, coag profile
• Serial exams; consider follow-up CT in 12-18hrs
• If deteriorates – repeat CT immediately, manage as severe
brain injury

30. SEVERETRAUMATIC BRAIN INJURY
3-8

32. Primary survey and resuscitation
• Intubation and ventilation
• Obtain GCS before sedating/paralyzing
• Ventilate with 100% O2 till ABG is obtained
• Maintain PaCO2 approx 35mm Hg
• Maintain spO2>98%
• Reserve hyperventilation in signs of herniation/acute neurological
deterioration only

33. Primary survey and resuscitation
• “Hypotension usually is not due to the brain injury itself, except in the
terminal stages when medullary failure supervenes or there is a
concomitant spinal cord injury”
• Seek and treat primary cause of hypotension
• Maintain SBP>100 for 50-69yrs; SBP>110 for 15-49 and >70yrs
• Neurological exam – GCS, pupils, focal neurological deficit
• Analgesics, anaesthetics, sedatives – use cautiously

34. • Serial examinations
• NCCT head
• Skull fractures, intracranial blood, contusions, mass effect, midline
shift, obliteration of basal cisterns
• Shift>5mm often requires surgery

35. MEDICALTHERAPIES FOR BRAIN INJURY

36. “If injured neural tissue is given optimal conditions in which to
recover, it can regain normal function”

37. • Intravenous fluids
• Maintain normovolemia
• IVF, blood and blood products
• RL or NS (avoid hypotonic fluids, avoid hyperglycamia and
hyponatremia)
• Monitor sodium levels
• Hyponatremia – brain edema
• Normalize anticoagulation

38. • Hyperventilation
• Reduces PaCO2
• Cerebral vasoconstriction
• If aggressive and prolonged- cerebral ischemia
• Limited
• Keep PaCO2 35mmHg
• Not recommended prophylactically

39. • Mannitol
• To reduce elevated ICP
• MC preparation – 20% (20g in 100ml)
• DOES NOT LOWER ICP IN HYPOTENSIVE PATIENT; acts as
osmotic diuretic rather – exacerbates hypotension – cerebral
ischemia
• Acute neurological deterioration – indication (Bolus 1g/kg over 5 min)
• 0.25-1g/kg dose

40. • Hypertonic saline
• Preferable for patients with hypotension
• Barbiturates
• To reduce ICP refractory to other measures
• Avoid in hypotension or hypovolemia

41. • Anticonvulsants
• Phenytoin and fosphenytoin in acute phase
• Loading dose of phenytoin 1g at max 50mg/min
• Maintenance 100mg iv 8 hourly
• Diazepam, lorazepam
• GA for prolonged seizures (30-60min)
• Not recommended for preventing late post traumatic seizures

42. SURGICAL MANAGEMENT

43. ScalpWounds
• Clean and inspect thoroughly before suturing
• Control scalp hemorrhage
• CSF leak – dural tear

44. Depressed skull fractures
• CT scan
• Exclude intracranial hematoma or contusion
• Operative elevation
• Depression> thickness of adjacent skull
• Open and grossly contaminated
• Less severe – close overlying scalp laceration

45. • Intracranial mass lesions – definitive neurosurgical care
• Penetrating brain injuries
• PlainCT head; plain radiographs if CT unavailable
• Prophylactic broad spectrum antibiotics
• Leave in place till possible vascular injury has been ruled out,
neurosurgical management established

46. Acute Epidural Hematomas
• Indications
• EDH>30 cu.cm, regardless of GCS – surgically evacuate
• EDH<30 cu. Cm, <15mm thickness, <5mm MLS,GCS>8, without
FND – nonoperatively with serial CT and close neurosurgical
observation
• Timing: Acute EDH in coma (GCS<9) with anisocoria – ASAP

47. Acute Subdural Hematomas
• Indications
• Acute SDH with thickness>10mm or MLS>5mm on CT,
regardless of GCS - operate
• Acute SDH in coma (GCS<9) – ICP monitoring
• Comatose patient with SDH<10mm thickness, MLS<5mm –
surgically evacuate if
• Fall in GCS 2 or more points between time of injury and hospital
admission
• Presents with asymmetric and fixed or dilated pupils
• And/or ICP exceeds 20 mm Hg
• Timing: ASAP

48. Traumatic parenchymal lesions
• Indications
• Parenchymal mass lesions and signs of progressive neurological
deterioration referable to the lesion, medically refractory
intracranial hypertension, mass effect on CT – operate
• GCS 6-8 with frontal or temporal contusions>20 cu.cm, MLS at
least 5mm and/or cisternal compression onCT, lesion>50cu.cm –
operate

49. Traumatic parenchymal lesions
• No e/o neurological compromise, controlled ICP, no significant mass
effect – nonoperative, monitoring, serial imaging
• Timing and methods:
• Focal lesions - Craniotomy with evacuation of mass lesions
• Diffuse, medically refractory posttraumatic cerebral edema & ICH -
Bifrontal decompressive craniectomy within 48hrs of injury
• With e/o impending transtentorial herniation – decompressive
procedures including subtemporal decompression, temporal
lobectomy, hemispheric decompressive craniectomy

50. Posterior fossa mass lesions
• Indications
• Mass effect on CT or with neurological dysfunction or
deterioration referable to the lesion – operate
• (Mass effect on CT – distortion, dislocation or obliteration of 4th
ventricle, compression or loss of visualization of basal cisterns or
obstructive ehydrocephalus)
• Nonoperative – no significant mass effect on CT, no signs of
neurological dysfunction
• Timing and methods: ASAP, suboccipital craniectomy

51. Depressed Cranial Fractures
• Indications
• Open (compound) fractures depressed > thickness of cranium –
operate
• Non operative
• Closed (simple) depressed cranial fractures
• No e/o dural penetration or significant intracranial hematoma or
depression >1cm or frontal sinus involvement or gross cosmetic
deformity or wound infection or pneumocephalus or gross
contamination

52. Depressed Cranial Fractures
• Timing and methods:
• Early operation
• Elevation and debridement
• Primary bone fragment replacement - in the absence of wound
infection
• Antibiotics

53. “NO HEAD INJURY IS MINORTO BE NEGLECTED
NOR SERIOUS ENOUGHTO BE GIVEN UP”
-Hippocrates

54. References
• ATLS Student Course Manual 10th Edition
• Handbook of Neurosurgery, Mark S. Greenberg, 8th Edition
• Guidelines for the Surgical Management ofTraumatic Brain Injury;
The BrainTrauma Foundation andThe Congress of Neurological Surgeons;
Neurosurgery Vol58 Number 3 March 2006 Supplement

55. THANKYOU
for your time