This document discusses cranio-cerebral injuries or traumatic brain injuries. It defines these injuries as damage to the skull or brain that interferes with normal function. It then discusses the classification, etiology, mechanisms of injury, diagnosis and management of such injuries. Traumatic brain injuries can be classified based on severity using the Glasgow Coma Scale or based on location of the injury in the brain. The mechanisms of injury include both primary injuries caused directly by the trauma and secondary injuries caused by processes initiated after the trauma such as increased intracranial pressure. Diagnosis involves tests such as CT scans and management focuses on stabilization, monitoring, controlling increased intracranial pressure and addressing complications.

1. TBI/HeadInjury/CRANIO–CEREBRAL
INJURIES
Ms.ShiwaniSah
Lecturer

2. DEFINITION
Cranio-cerebral injuries (or) traumatic brain
injury are general designations to denote
injury to the skull ,brain which interfere
with normal function and require treatment .

3. ETIOLOGY
A. Road traffic accidents
B. Falls
C. Physical assaults
D. Accidents at home, work, outdoors
E. While playing sports

4. CLASSIFICATION
BASED ON SEVERITY OF INJURY
ACCORDING TO GLASSGOW
COMA SCALE
BASED ON LOCATION

5. SEVERITY OF INJURY ACCORDING TO
GLASSGOW COMA
Glassgow
coma scale
(GCS)
Mild brain
injury
GCS : 13-15
Moderate
brain injury :
GCS :9-12
Severe Brain
Injury :
GCS : 3-8

6. ACCORDING TO LOCATION
SCALP
Contusion
Abrasion
Laceration
Subgaleal
hematoma
SKULL
Skull fracture
Linear
Comminuted
Depressed
Basilar
Facial fracture
Mandible
Zygoma
Nasal
Orbital
MENINGES
Dural tear
BRAIN

10. SKULL/ FACIAL FRACTURES

11. ACCORDING TO LOCATION
BRAIN
Focal
Contusion Laceration Hemorrahage
EDH SDH SAH
Intracerebral
hematoma
Diffuse
Concussion Diffuse axonal injury

12. MECHANISM
There are two main mechanisms in the development of brain damage
1. Primary injury : It comes through direct contact to the head and brain as
an immediate result of the initial insult at the moment of injury
2. Secondary Injury : It results from systemic or intracranial processes
initiated at the moment of injury such as hypotension, hypoxia , intracranial
hypertension, intracranial haemorrhage . Edema, seizures, vasospasm ,cerebral
ischemia leads to neuronal injury

13. PRIMARY BRAIN INJURY
Mechanical force that strikes the head in motion causes cellular damage.
These mechanical forces are differentiated as impact, strain or
compression.
1. Impact loading involves direct contact of an object to the head which
results in skull deformation / fractures
2. Strain is the result of a blunt acceleration, deceleration or rotational
forces applied to brain tissue that tear or shear the brain vessels & cells
3. Compression are prolonged static forces applied to brain tissue that
distort tissue, alter perfusion and result in increased ICP

14. PRIMARY BRAIN INJURY
Acceleration injuries are the result of a moving object striking the head
Deceleration injuries result from the moving head striking an immobile object
The effects are scalp laceration, skull fracture, EDH, Contusions, intracerebral
hemorrahge

15. PRIMARY BRAIN INJURY
A special type of acceleration – deceleration motion is rotation also
called angular acceleration
It is responsible for two types of injury i.e SDH, Diffuse axonal injury

16. SECONDARY BRAIN INJURY
Secondary injury is a delayed , physiologic response to the primary
injury
Following the primary injury there will be massive depolarization that
occurs which leads to a number of neuropathological changes including
the activation of biochemical, metabolic, inflammatory cascades which
may lead to ischemia, cerebral edema, inflammation and neuronal death

19. PATHOPHYSIOLOGY
TRAUMATIC BRAIN INJURY
Primary injury comes
(direct contact to the head and brain as
an immediate result of the initial insult
at the moment of injury)
The cerebral injury
Focal (contusion or laceration) Diffuse
(concussion or diffuse axonal injury).
Secondary injury (results from complicating
processes)
Initiated at the moment of injury, which present
later in the clinical course.
Intracranial haemorrhage, cerebral edema
Increased intracranial pressure (ICP), hypoxic
(ischemic) brain damage, and infection
Results in cerebral ischemia, unleashing the ischemic cascade and other
biochemical changes on the cellular level that can lead to neuronal injury and cell death

21. DIAGNOSIS
&
MANAGEMENT

22. Diagnosis
Complete blood count
Arterial blood gas
Serum electrolytes, glucose, creatinine, and blood urea nitrogen
Serum alcohol level
Chest radiograph
Spine films usually cervical but may include thoracic and lumbar, as indicated
Computed tomography (CT)
Pelvis radiograph to exclude fracture
Focused abdominal sonography in trauma (FAST) examination to evaluate for abdominal trauma

23. SCALP INJURIES
INJURY MANAGEMENT
Abrasion The area is cleaned & dressed
Scalp contusion Application of Ice to prevent
hematoma. No specific
treatment
Laceration Suturing may be necessary
Subgaleal hematoma It will usually absorb on its
own

24. SKULL FRACTURE
CT Scan is used to diagnose a skull fracture. But the basal skull fracture is
well appreciated by MRI.

25. BRAIN INJURIES
Focal
Contusions,
hematomas
(SDH,EDH,ICH)
Diffuse
DAI, TSAH

26. PRE-HOSPITAL MANAGEMENT
A- Airway
B- Breathing
C- Circulation
D- Disability

27. EMERGENCY MANAGEMENT
Activities of health care professional on arrival :
1. Attaching monitoring equipment
2. ECG
3. Primary & secondary survey
4. Inserting arterial & central lines
5. Indwelling urinary catheter
6. Resuscitation & stabilization treatment

28. EMERGENCY MANAGEMENT
History to be collected:
A. Mechanism of injury ( Eg: direct blow to head, thrown from car, fell off )
B. Was seat belt or helmet worn? ( type of seat belt : lap or shoulder? )
C. How patient was found?
D. LOC ( Immediate or Lucid period )
E. Documented apnea or cyanosis
F. Was there significant blood loss?

29. COMMON DIAGNOSTIC TESTS
UPON ARRIVAL
CBC, ABG, Sr. Electrolytes, BUN
Drug screening
Sr. Alcohol Level
Chest radiograph
Spine screening
FAST scan
CT Scan- Abdomen /Pelvis
Urine ouput

30. INTENSIVE CARE MANAGEMENT
Systemic monitoring
Cerebral monitoring
Management of ICH
Cerebrospinal fluid drainage
Sedation, Analgesics & Neuromuscular blockade
Hyperventilation
Seizure management
Cerebral monitoring
Multisystem management

31. SYSTEMIC MONITORING
I. Cardiac rhythm monitoring –cardiac monitor
II. Oxygen saturation- pulse oximetry
III. ABP & Etco2 monitoring – arterial line
IV. CVP monitoring to monitor patients fluid volume status
V. Strict intake –output chart – hydration status
VI. Regular monitoring of glucose , electrolytes and arterial blood gases

32. MANAGEMENT OF INTRACRANIAL
HYPERTENSION
ICH may cause displacement and herniation of brain causing death
Therefore ICH management is an integral part of care
Applying the Monro –kellie principle of decreasing intracranial
hypertension by decreasing the intracranial contents by following
interventions
Mannitol or hypertonic saline – to decrease the brain size
Drainage – to decrease CSF
Removal of bone flap (Craniectomy ) – to decrease blood

33. SEDATION, ANALGESICS &
NEUROMUSCULAR BLOCKADE
Sedation and analgesics are important management strategies in TBI patients
It can be used to treat or prevent spikes in ICP related to agitation, restlessness,
abnormal posturing , asynchrony with mechanical ventilation
Lorazapem and midazolam are more commonly used but have difficulty in performing
neurological assessment
1-10% of ICU patients receive NMB drugs . They are used when sedation and analgesia
are not enough to control ICH
Drugs commonly used are rocuronium, vecuronium etc. These drugs induce paralysis
and can mask neurological changes such as seizure
Patient may develop myopathy after extended use.

34. Ineffective breathing pattern related to weakness or paralysis of diaphragm
Ineffective airway clearance related to muscle weakness and inability to clear secretions
Acute pain related to injury
Impaired physical mobility related to motor and sensory impairment
Risk for impaired skin integrity related to immobility and sensory loss
Impaired urinary elimination related to inability to void spontaneously
Constipation related to presence of atonic bowel
NursingDiagnosis