Lecture notes for medical students

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5. This will be an ACTIVE LEARNING SESSION x
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6. Good for self study also.
7. See notes for bibliography.

2. Checklist

3. Checklist
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

4. Checklist
• Definitions
– Glasgow Coma Scale
– Intracranial Pressure
• Mechanisms of brain injury
• Evaluation of head injury
• Management of head injury
– Operative
– Nonoperative

5. Spectrum of injury
• Laceration
• Contusion
• Fracture
• Haemorrhage - extradural, subdural,
subarachnoid, intraparenchymal
• Diffuse axonal injury

6. 1. Primary Injury :
Damage at the time
of injury
2. Secondary Injury:
Complications after
initial injury
Traumatic Brain Injury

7. Traumatic Brain Injury
Primary damage
• Cerebral laceration
• Cerebral contusion
• Dural sac injury - bleeds
• Diffuse axonal injury

8. Traumatic Brain Injury
Secondary damage
• Raised ICT
• Intracranial hemorrhage
• Infection
• Brain Oedema

9. Glasgow Coma Scale (GCS)

10. Mechanisms of Traumatic Brain
Injury

11. Mechanisms of Traumatic Brain
Injury
• Impact injury
• Cerebral or brainstem contusions
• Cerebral lacerations
• Diffuse axonal injury (DAI)
• Secondary injury
• Intracranial hematoma
• Edema
• Ischemia

12. History - Mechanism
• Height of fall/ speed of impact
• Weapon/ surface
– pointed/ flat
– hard/ soft
• Site of impact

13. History - patient
• Alcohol/ Drugs/ pre-trauma state
• Loss of consciousness/ Seizure
• Amnesia/ Headache
• Vomiting

14. Examination
• General
• Head/scalp
• PNS/CNS incl AMS
• Cerebellar signs/gait

15. Abbreviated Mental State
• Age • Place
• Dob • Identify 2 people
• Time (nearest hour) • WWII dates/ as appropriate
• Address for recall • Current PM/Monarch
• Year • Serial 3’s
• Check address recall

16. Initial Assessment
History
– LOC +/-
– Intoxicants
– Seizure
– Posttraumatic amnesia
• Physical Exam
– GCS
– Level of consciousness
– Cranial nerves
– Fundoscopic exam
– Motor exam
Start with ABC’s

17. Radiographic Evaluation

18. Radiographic Evaluation
• CT
• Imaging study of choice for initial work-up
• MRI
• More helpful later in hospital course
• Skull x-rays
• Arteriography

19. GCS<13 at any point
GCS 13-14 at 20
Focal deficit
? Open/depressed/Basal #
Post-traumatic seizure
> 1 vomiting episode
LoC or ante grade amnesia
No imaging now
CT within 1hr
+ Get help!
-
NICE Guidelines 03
Age  65
Coagulopathy/warfarin
+
+
Dangerous Mex:
pedestrian rta, ejection,
fall > 1m / 5stairs.
Retrograde
amnesia>30mins
-
-
-
CT within 8hrs
+

20. Indications for CT

21. Indications for CT
• Presence of any criteria placing patient at
moderate or high risk for intracranial injury
• Assessment prior to general anesthesia for
other procedures

22. Head Injury Management

23. Head Injury Management
• Nonoperative
• Seen in absence of significant intracranial mass
lesion.
• Typically consists of assessment and/or treatment of
intracranial pressure (ICP).
• Operative
• Typically required when a significant intracranial
mass lesion is present.
• Decompressive craniectomy or brain resection less
common.

24. • Guidelines of Advanced Trauma Life Support
(ATLS) provide a standardized protocol for
approaching the severe brain injury patient.
• Hypoxemia.
• Hypercarbia/hypocarbia.
• Hypotension/hypertension.
• Fluid resuscitation.
• PH.

25. Hypoxemia
Chowdhury T, Kowalski S, Arabi Y, Dash HH. Pre-hospital and initial management of head injury patients: An update. Saudi Journal
of Anaesthesia. 2014;8(1):114-120.

26. Hypoxemia
• First most important consideration
– Maintenance of a clear and unobstructed airway.
• Hypoxemia is the most important factors
related to worse outcome.
• Intubation should be done if needed.
• Before attempts of intubation are done
– Administration of O2 by mask.
– Intravenous infusion of normal saline.
Chowdhury T, Kowalski S, Arabi Y, Dash HH. Pre-hospital and initial management of head injury patients: An update. Saudi Journal
of Anaesthesia. 2014;8(1):114-120.

27. • Indications of Intubation
– Coma (GCS<8).
– Loss of protective reflexes.
– Ventilatory insufficiency.
– Spontaneous hyperventilation.
– Bilateral fracture mandible.
– Pulmonary edema.
– Seizure.
Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HM, Jagoda AS, et al. Brain Trauma Foundation; BTF Center for Guidelines
Management. Prehosp Emerg Care. 2008;12(Suppl 1):S1–52.

28. Hypotension/hypertension
Guidelines.Pearson WS, Ovalle F Jr, Faul M, Sasser SM A review of traumatic brain injury trauma center visits meeting
physiologic criteria from The American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention
Field Triage Prehosp Emerg Care. 2012 Jul-Sep; 16(3):323-8.

29. Hypotension/hypertension
• Hypotension is a major secondary brain insult.
• Single episode of hypotension dramatically
worsens the outcome.
• Dopamine, as a vasopressor is very popular
amongst physicians.
• Major disadvantages of dopamine
– Tachycardia, aggravation of brain edema
• Low-dose noradrenaline.
Guidelines.Pearson WS, Ovalle F Jr, Faul M, Sasser SM A review of traumatic brain injury trauma center visits meeting
physiologic criteria from The American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention
Field Triage Prehosp Emerg Care. 2012 Jul-Sep; 16(3):323-8.

30. • Hypertension may be a physiological response
produced due to sympathetic surge.
• Hypertension should not be treated unless
– Cause has been excluded or treated.
– Systolic blood pressure is >180-200 mmHg.
– MAP is >110-120 mmHg.
• Infusion of short-acting beta blocker
– Do not cause cerebral vasodilatation.
Badjatia N, Carney N, Crocco TJ, Fallat ME, Hennes HM, Jagoda AS, et al. Brain Trauma Foundation; BTF Center for Guidelines
Management. Prehosp Emerg Care. 2008;12(Suppl 1):S1–52.

31. Fluid resuscitation
• Prompt resuscitation with fluids is of
paramount importance to preserve optimum
cerebral perfusion pressure (CPP).
• However, the choice of fluids is still a matter
of great conflict.
Bulger EM, Guffey D, Guyette FX, MacDonald RD, Brasel K, Kerby JD, et al. Impact of prehospital mode of transport after severe injury:
A multicenter evaluation from the Resuscitation Outcomes Consortium. J Trauma Acute Care Surg. 2012;72:567–73.

32. • Infusion of normal saline is recommended as
it is isotonic.
• Administration of glucose-containing fluids is
contraindicated in the prehospital phase
– It may aggravate ischemia and brain edema.
• Small volume resuscitation is a promising
concept.
Brasel KJ, Bulger E, Cook AJ, Morrison LJ, Newgard CD, Tisherman SA, et al. Hypertonic resuscitation: Design and implementation
of a prehospital intervention trial. J Am Coll Surg 2008;206:220-32.

33. Therapy for Intracranial
Hypertension

34. Therapy for Intracranial
Hypertension
• First tier
• Positioning
• Ventricular drainage
• Osmotic diuresis
• Hyperventilation (Level III – temporizing measure)
• Second tier
• Sedation
• Neuromuscular blockade
• Hypothermia
• Barbiturate coma
• Glucocorticoids not recommended (Level I)

35. Operative Management

36. Operative Management
• Types of mass lesions
• Epidural hematoma
• Subdural hematoma
• Cerebral contusion
• Decompressive craniectomy/brain resection

37. • Severe head injury patients impose very high
mortality and morbidity.
• Substantial portion of these bad outcomes can
be prevented by prompt evaluation and pre-
hospital as well as early emergency
management.
• Management strategies comprise of rapid
correction of hypoxemia and hypotension.

39. Epidural Hematoma (EDH)

40. Epidural Hematoma (EDH)
• 1% of head trauma admissions
• Male: Female = 4:1
• Source of bleeding is arterial in 85% of
cases (middle meningeal artery)
• Mortality ranges from 5-10% with optimal
management
• Neurological injury caused by secondary
mechanisms

43. Subdural Hematoma (SDH)

44. Subdural Hematoma (SDH)
• About twice as common as EDH
• Mortality 50-90%
• Impact injury much higher than with EDH
• Often associated brain injury
• Two common sources of bleeding
• Tearing of bridging veins
• Cortical laceration

45. Cerebral Contusion

46. Cerebral Contusion
• Often little mass effect
• Not often operative

48. Pre-op Post-op
Hemicraniectomy

49. Key Points
• 2 mechanisms of brain injury
• Impact injury
• Secondary injury
• GCS < 8 has generally become accepted as representing
coma / severe head injury
• CT is generally the imaging study of choice in the acute
assessment of head injury
• Operative and nonoperative strategies are generally aimed
at reducing mass effect and, therefore, reducing ICP
• Nothing beats a neuro exam.

50. Key Points

51. Key Points
• 2 mechanisms of brain injury
• Impact injury
• Secondary injury
• GCS < 8 has generally become accepted as representing
coma / severe head injury
• CT is generally the imaging study of choice in the acute
assessment of head injury
• Operative and nonoperative strategies are generally aimed
at reducing mass effect and, therefore, reducing ICP
• Nothing beats a neuro exam.

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