1) Head trauma can cause permanent injury, with motor vehicle crashes and falls being common causes. Approximately 30% of those with moderate head trauma have at least one other significant concurrent injury. 2) Primary brain injury results directly from trauma and causes bleeding, tearing and shearing of brain tissue. Secondary brain injury can occur later and includes hypoxia, swelling and increased pressure inside the skull. 3) Various types of head injuries are discussed, including scalp lacerations, skull fractures, concussions, contusions and bleeding within or around the brain. The Glasgow Coma Scale is used to assess level of consciousness.

1. Brain and Craniofacial Trauma Lt. Colonel Brenda Sowards, RN

2. Head Trauma 50-99% of moderate head trauma victims have permanent injury. Motor Vehicle Crashes are primary cause. Falls for elderly and children High velocity missiles/blast injuries 30% have at least one significant concurrent injury.

4. Pathophysiology Primary brain injury Direct Trauma Involves bleeding, tearing, shearing, neuron damage Secondary brain injury Hypoxia, hypercapnea, hypotension, hyperglycemia, hypoglycemia, increased intracranial pressure, swelling, seizures

5. Head Injuries Scalp Lacerations Skull Fractures Concussions Contusions Intracranial Bleeding Cerebral Edema

6. Scalp Lacerations Rich blood supply Can cause hypovolemic shock Often deeper brain injury has occurred Direct pressure to control bleeding Do not apply excessive pressure Complete neurological exam

7. Skull Fractures Significant force has been applied to the skull. Injuries from bullets, blasts,blunt force, other penetrating objects. Risk of infection, if open skull fracture. X-ray or CT Deformity Skull fragments

8. Skull Fractures Raccoon Eyes Indicates maxilofacial fractures around eyes Ecchymosis (Black eyes) Visual Acuity Eye bulges out (Exopthalmos) Eye sinks in (Enopthalmos)

9. Skull Fractures Battle’s sign Associated with basilar skull fracture Blood accumulation behind one or both ears (forms bruising 12-24 hours later) Hemotympanum CSF drainage from ears or nose (never pack) Check extraocular movements

10. Concussion Temporary loss of brain function May result in loss of consciousness Confusion Amnesia Dizzyness Weakness

11. Concussion Coup- same side injury Contra-coup-opposite side injury Contusions may occur as the brain scrapes the inside of the skull Bleeding, permanent injury, swelling, amnesia, unconsciousness

12. Intracranial Bleeding Epidural Hematoma Subdural Hematoma Intracerebral Hemorrhage

13. Epidural Hematoma Occurs above the dura lining Occurs below the skull Most often arterial bleeding Develops rapidly Rapid deterioration of neurologic functions Lucid phase

14. Subdural Hematomas Occurs beneath the dura Occurs outside the brain Usually venous in nature Develops slowly Progressive loss of neurological function Patients may not remember blunt trauma

15. Intracranial Hemorrhage Bleeding occurs within the brain itself Caused by tearing, shearing of blood vessels Spinal Taps contraindicated due to increased swelling

16. Cerebral Edema Most common complication of head injury Aggravated by low oxygen levels Seizures increase oxygen consumption Causes increased intracranial pressure Normal ICP 10-15 mm

17. Cerebral Ischemia Headache Nausea and vomiting Amnesia for events before or after injury Altered level of consciousness Restlessness, drowsiness Changes in speech Loss of judgement

18. Intracranial Pressure Cerebral Perfusion Pressure (CPP) Mean Arterial Pressure (MAP) Autoregulation

19. Autoregulation An increase in mean arterial pressure leads to vasoconstriction of cerebral vessels. A decrease in mean arterial pressure leads to vasodilation of cerebral vessels. Hypoxia and Hypovolemia are the main causes of secondary brain injury.

20. Intracranial Pressure Cerebral perfusion must be adequate to prevent secondary brain injury. Prevention starts by treating shock. Keep mean arterial pressure between 60 and 180 mm Hg. One episode of hypotension significantly increases morbidity and mortality. Position patient to facilitate venous drainage.

21. Monro-Kellie Doctrine

22. Glasgow Coma Scale EYE OPENING Spontaneous To Voice To Pain None 4 3 2 1

23. Glasgow Coma Scale VERBAL RESPONSE Oriented Confused Inappropriate Words Incomprehensible Words None 5 4 3 2 1

24. Glasgow Coma Scale MOTOR RESPONSE Obeys Commands Localizes Pain Withdraws (pain) Flexion (pain) Extension (pain) None 6 5 4 3 2 1

25. Glasgow Coma Scale Predicts mortality Measures level of consciousness Motor component most sensitive subset Indicates improvement or deterioration GCS of 9-15 indicates mild to moderate injury GCS of 3-8 indicates severe head injury

26. Pupil Assessment Size Light Response Equal Compare

27. Posturing Decorticate- hands turn inward toward Decerebrate-hands turn outward Happens prior to herniation syndrome.

28. Treatment Prevent secondary injury Airway-oxygen and intubation if GCS < 8 Treat shock-normotensive Hyperventilation is only indicated if patient shows signs of impending herniation Control bleeding from other injuries RAPID transport if possible

29. Treatment Continual assessment-pupils & GCS Treat seizures-increased oxygen consumption of the brain Watch for respiratory pattern changes-may indicate your patient is worsening.

30. Management of Suspected Traumatic Brain Injury

31. QUESTIONS ?