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Head injury by Dr. sumit sinha
1. HEAD INJURY
Dr Sumit Sinha MBBS, MS, DNB, MCh
Faculty, AO Spine
Faculty, Advanced Trauma Life Support
Associate Professor, Deptt of Neurosurgery,
AIIMS and JPNATC, New Delhi
2. Objectives
• Anatomy and Pathophysiology of CNS trauma.
• Assessment and treatment
• Identify indications for spinal immobilization.
3. Head and Brain Trauma
• Worldwide, there are approximately:
– 200 to 300 cases of TBI per 100,000 population
– 25 cases of severe TBI per 100,000 population
• In the US:
– 4 million head injuries/ year
– 1.4 million treated in hospitals
– 300,000 admitted/ year
– 90,000 with residual neurologic deficit
4. Anatomy: Skull and Brain
Skull
Periosteum
Dura mater
} One functional layer
Arachnoid membrane
Pia mater
Vessels in
subarachnoid
space
Epidural space
Subdural space
Subarachnoid space
5. Anatomy: The Brain
• Frontal lobe
– Foresight, planning,
judgment,
movement
• Parietal lobe
– Sensation from body
surface
• Temporal lobe
– Hearing
– Speech
• Occipital lobe
– Vision
6. Pathophysiology of CNS Injury
• Primary injury
– Damage that occurs at the moment of impact
• Secondary injury
– Damage that occurs subsequent to the initial
impact
• Systemic causes
• Intrinsic causes
7. Brain Metabolism and Perfusion
• Perfusion of the brain depends on maintaining
Cerebral Blood Flow (CBF).
• Flow requires pressure gradient, referred to as Cerebral
Perfusion Pressure (CPP).
– CPP is the pressure that keeps blood moving through the
brain.
• Autoregulation allows BP changes to maintain CPP.
• CPP = Mean Arterial Pressure (MAP) – Intracranial
Pressure (ICP)
• ICP is usually 10 to 15 mm Hg
8. Intracranial Pressure
• Intracranial contents include:
– 80% brain tissue
– 10% blood
– 10% cerebrospinal fluid
• Intracranial volume or space is fixed.
9. Intracranial Pressure
• An increase in the volume of any of the three
contents may cause increased ICP.
– Swelling
– Bleeding
– CSF accumulation
10. Intracranial Pressure
• As ICP increases, everything in the skull is
compressed:
– Blood vessels
– CSF
– Brain
• You can displace a small amount of blood;
• You can displace a small amount of CSF;
• But…
12. Pathophysiology of Brain Injury
• As ICP ↑ and approaches MAP, CBF ↓ ⇨ ↓ CPP.
– Compensatory mechanisms attempt to ↑ MAP.
– As CPP ↓, cerebral vasodilation occurs to ↑ blood
volume, and the body tries to ↑ CBF.
– This leads to further ↑ ICP, ↓ CPP, and so on.
– If pressure inside the skull exceeds mean arterial
pressure, blood flow to brain stops
(CPP = MAP – ICP).
13. The Endless Cycle…
• In the case of EDH or SDH, we can also add
the effect of the expanding hematoma.
14. Clinical Effects of ↑ ICP
• Pressure exerted down on the brain
– Cerebral cortex and RAS
• Altered level of consciousness
– Hypothalamus
• Vomiting
15. Clinical Effects of ↑ ICP
• Pressure exerted down on the brain
– Brain stem
• ↑ BP to force blood into the brain against ↑ ICP
• Bradycardia 2° vagal stimulation and ↑ BP
• Irregular respirations (↑ CO2) or tachypnea (↓ CO2)
• Unequal/unreactive pupils 2° cranial nerve III
compression
• Abnormal posturing (flexion or extension)
• Seizures
– Herniation of the brain
16. Patient Assessment
• Primary Survey
– Determine the mechanism of injury and the need
to consider possible spine injury.
– Airway compromise?
– Ventilatory compromise?
– Adequate oxygenation?
– Adequate circulation and perfusion?
• Neurologic Assessment for Disability
17. Patient Assessment
• The complete neurological exam consists of
six components:
– Mental status (MS)
– Cranial nerves
– Motor response
– Sensory response
– Coordination
– Reflexes
18. Mental Status–AVPU
• Initial Impression–how sick is this patient?
– Alert
– Responds to Verbal stimulus
– Responds to Painful stimulus
– Unresponsive
19. Glasgow Coma Scale
Eye Opening
Spontaneous = 4
To Voice = 3
To Pain = 2
None = 1
Verbal Response
Oriented = 5
Confused = 4
Inappropriate Words = 3
Incomprehensible Sounds = 1
None = 1
Motor Response
Follows Commands = 6
Localizes Pain = 5
Withdraws = 4
Flexion = 3
Extension = 2
None = 1
• Use the modified GCS
for pediatrics.
• WHEN do you score
the GCS?
AFTER the correctible
causes of altered mental
status have been
addressed
20. Traumatic Head and Brain Injury
• Mechanism of Injury
– Blunt
– Penetrating
• Type of Injury
– Closed
– Open
22. Primary Brain Injury
• Skull fracture
– Injury to the brain’s protective case
– Indicates significant force,
• So you have to ask…
“What happened to the brain (and neck)?”
– Presence increases suspicion for intracranial hematoma
and TBI
– Types of skull fractures
• Linear (80%)
• Depressed
• Open/closed
• Basilar
23. Primary Brain Injury
• Concussion
– Temporary period of abnormal neurological
function that returns to normal without visible
structural damage to the brain.
24. Primary Brain Injury
• Brain contusion
– Bruising of brain tissue
– Signs and symptoms
• Altered mental status
• Loss of consciousness
• Vomiting
• Focal neurologic abnormalities
– Depending on the area of the brain injured
– May be associated with cerebral edema causing
increased ICP
26. Subarachnoid Hemorrhage
• The most common post-traumatic intracranial
bleed
• Signs and symptoms
– Headache
– Nausea, vomiting
• May cause increased ICP, vasospasm,
impaired cerebral circulation
28. Diffuse Axonal Injury
• Widespread damage to the nerve axons
• Symptoms
– Diffuse cerebral edema
– Loss of consciousness
– Increased ICP
29. The Bottom Line…
• So… how do you know, in the field, what brain
injury your patient has?
• Most of the bad TBI stuff presents about the
same way:
• Headache
• Vomiting
• Altered mentation
• Neurologic deficits
30. Assessment of Head Injury
• Change in LOC- earliest and best indicator of
patient’s ICP.
– Evaluation methods
• AVPU system
• GCS score
• Early detection of increasing ICP is critical–
before herniation has occurred.
Assess and re-assess
31. Intracranial Hypertension
• Warning signs of possible increasing ICP and
impending herniation
– Decline in GCS score of 2 points or more
– Development of sluggish or nonreactive pupil
– Development of hemiplegia or hemiparesis
– Cushing’s phenomenon
33. Prehospital Care of CNS Trauma
• ABCs
• Spinal motion restriction
• Initial resuscitation
• Rapid transport
34. Management of CNS Trauma
– Open it.
• Maintain spinal
motion restriction
• Jaw thrust
– Clear it.
• Use suction as
needed.
– Maintain it
• GCS 9 or more ?
Able to maintain
patency?
– If not, use airway
management.
Airway
MONITOR:
Oxygen saturation
(95% or higher)
Blood pressure
ETCO2
35. Management of CNS Trauma
• Studies have shown that prehospital
intubation and RSI have been associated with
worse patient outcomes.
• RSI has been associated with:
– Hypoxia
– Hypercarbia
– Hypocarbia
– Hypotension
36. Management of CNS Trauma
Breathing
– Provide oxygen (100%)
– Assist ventilations (as needed)
• Maintain normal EtCO2 35 to 40 mm Hg
• Rate:
– Adults: 10 to 12 breaths per min
– Peds: 12 to 20 breaths per min
NO ROUTINE hyperventilation
37. Management of CNS Trauma
• Hyperventilation indicated for:
– Bilateral dilated and unresponsive pupils
– Unequal pupils (with altered LOC)
– Abnormal posturing
– Neurologic deterioration (decrease in GCS of two
or more points in patient with initial GCS <9)
Target – EtCO2 30 to 35 mm Hg
38. Management of CNS Trauma
Circulation
– Prevent anemia: control hemorrhage.
EVERY RBC COUNTS!
– Maintain adequate BP and perfusion.
– If BP is normal or elevated:
• IV of LR/NS
– If BP is decreased:
• IV of LR/NS bolus, titrate BP to a minimum of 90 mm Hg
40. Summary
• Identify the mechanism of injury.
• Primary survey: identify and treat life-
threatening conditions first.
• Shock is a late finding in patients with TBI;
consider the possibility of internal
hemorrhage.
41. Summary
• Assess indications for immobilization.
– When in doubt, immobilize.
• The most important sign of TBI is a change in
mental status.
• Key aspect is to determine if baseline
assessment findings are changing and in
which direction (better or worse).
