2. A&E(VMH)
Head Injury
• Number One Killer in
Trauma
• 25% of all trauma deaths
• 50% of all deaths from MVC
• 200,000 people in the world
live with the disability
caused by these injuries
22. A&E(VMH)
Intracranial Pressure
• The pressure of the brain contents within the skull is
intracranial pressure (ICP)
• The pressure of the blood flowing through the brain is
referred to as the cerebral perfusion pressure (CPP)
The pressure of the blood in the body is the mean
arterial pressure (MAP)
CEREBRAL BLOOD FLOW
Normal CBF – 50ml/100gm of brain/min
“AUTOREGULATION”
24. A&E(VMH)
Intracranial Pressure
• Cerebral Perfusion Pressure (CPP) can be
determined by the following formula:
CPP = MAP - ICP
• Normal CPP range is 60 - 150 for autoregulation to
work well!
27. A&E(VMH)
Secondary Injury
• Neurologic outcome after head trauma - degree of secondary
brain injury.
• Common Secondary systemic insults –
Hypotension – SBP < 90
Hypoxia - Po2 less than 60
Anemia – reduces O2 Carrying capacity of the blood, to the
injured brain tissue,
• Other causes - hypercarbia, hyperthermia, coagulopathy, and
seizures.
39. A&E(VMH)
• Subdural hematomas
• Most frequently from
tearing of a bridging vein
between the cerebral
cortex and a draining
venous sinus.
• - acute - <24hrs
- subacute – 24hrs-2wks
- chronic - >2wks
SDH
Shape-
Crescent
40. A&E(VMH)
Intra Cerebral Heamatoma
• Formed within brain tissue & caused by shearing or
tensile forces that mechanically stretch and tear deep
small caliber arterioles
• Most common in temporal and frontal regions
• C/F depend on site involved
42. A&E(VMH)
Concussion
• Temporary & brief interruption of neurological
function after minor head injury
• Due to shearing / stretching of white matter fibres at
the time of impact or temporary neuronal dysfunction
• C/o headache, confusion, amnesia
• CT/MRI cannot detect
43. A&E(VMH)
DAI
• Shearing forces disrupt
the axonal fibres in the
white matter
• Shaken baby syndrome
• Blunt trauma
• Rapid rise in ICT.
• Prolonged or
permanent.
44. A&E(VMH)
APPROACH TO A PATIENT WITH
HEAD INJURY
• History
• Initial Assessment
Primary Survey
Secondary Survey
46. A&E(VMH)
• Breathing and ventilation : Intubation precautions
Pre-medicate with Lidocaine, 1mg/kg IV 2 minutes
prior to attempt
• Laryngoscopy produces an ICP Spike
Intubation with Cervical inline
stabilization
52. A&E(VMH)
MANAGEMENT OF
MILD HEAD INJURY(GCS13 -15)
• History
• General Examination
• Limited Neurologic Examination
• C-spine and other X-rays as indicated
• CT scan
53. A&E(VMH)
CRITERIA FOR ADMISSION
• No CT scanner available
• Abnormal CT scan findings
• All penetrating head injuries
• Skull fractures
• CSF leak
• Deteriorating level of consciousness
• Moderate to severe headache
• Significant alcohol / drug intoxication
• Significant associated injuries
55. A&E(VMH)
MANAGEMENT OF MODERATE
HEAD INJURY(GCS 9-12)
• Initial Examination
- Same as for mild head injury
- CT scan brain – obtained in all cases
- Admission for observation
• After Admission
Frequent Neurologic Checks
Improved Deteriorates (10%)
• Discharge
• Follow up
• Repeat CT scan
• Manage as per severe
head injury protocol
56. A&E(VMH)
MANAGEMENT OF SEVERE HEAD
INJURY(3 - 8 )
• Primary Survey and Resuscitation
• Secondary Survey and ‘AMPLE’ history
• Admit to facility – neurosurgical care
• Neurologic Re-evaluation
– Eye opening
– Motor response
– Verbal response
– Pupillary reaction
57. A&E(VMH)
• CT scan only after hemodynamic stabilization
• Medical therapy for raised ICP
• Immediate neurosurgeon opinion
• If needed surgical management
58. A&E(VMH)
• Head end elevation – 30 deg
• Intravenous fluids:
• Maintain normovolemia
• Hypotonic/glucose containing fluids
should not be used
• Serum sodium levels monitored daily
MEDICAL THERAPIES FOR HEAD
INJURY
59. A&E(VMH)
Mannitol
• 0.25-1g/kg
• Osmotic agent- dec ICP, maintains CBF,CPP and brain
metabolism
• Dec ICP within 6 hrs.
• Expands volume, O2 carrying capacity.
• Diuretic effect- net intravascular volume is reduced.
66. A&E(VMH)
SUMMARY
• Endotracheal intubation if GCS < 8
• Moderate hyperventilation
• Treat shock aggressively
• Resuscitate with normal saline or Ringer’sLactate solutions.
• Goal is to achieve a euvolemic state
contd..
67. A&E(VMH)
SUMMARY
• Frequent neurological assessment
• Exclude cervical spine injuries
• Transfer all moderate to severe head injured patients if neuro
surgeon is not available at your facility
