1) Critical care for head injury patients involves managing increased intracranial pressure (ICP) to prevent herniation and death. Nursing management includes measures to decrease blood and cerebrospinal fluid volume like osmotic diuretics. 2) Monitoring a patient's Glasgow Coma Scale (GCS) and FOUR score can assess severity of injury from mild to severe. One point increase in FOUR score can reduce mortality by 36% and improve neurological outcomes. 3) Initial resuscitation of severe traumatic brain injury focuses on securing the airway, ensuring oxygenation and circulation to optimize cerebral perfusion pressure and prevent secondary insults like hypotension and hypoxia. Close monitoring of vital signs and neurological status is

1. Critical care to
Head-Injured Patient
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คณะพยาบาลศาสตร์ มหาวิทยาลัยมหิดล

2. Brain tissue injury
Inflammatory & cerebral edema
vasodilation
 ICP
 CBF
Brain tissue
hypoxia
Cell death
Necrotic
tissue
edema
Further
 ICP
Herniation &
compress
brain stem
 ICP from
 Blood volume
Death
Accumulate
CO2
Vasodilation

3. CBF
24-48 hours after injury,
CBF  to base line
The brain is already swollen
Cause exacerbate neuronal injury
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4. Severe TBI (GCS = 3-8)
 obtain CT brain
 secondary insult; hypotension, hypoxia
1survey &
resuscitation
Airway & breathing
 Assisting in ET intubation
 Monitoring blood gas
 Monitoring O2 sat
Circulation
 Volume replacement
 Assisting in FAST, DPL
 IV fluid
 Monitor : V/S, LOC
Neurological
examination
 Assess GCS, pupil,
motor response
 Monitor : V/S, N/S, GCS
Re-assess
Record & repot
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2survey &
management
 Assess GCS, pupil
reaction, lateralization,
 Assess herniation
 Repeated CT scan
 Assisting in diagnostic
test, surgical treatment

5. Initial brain resuscitation
 ABCs
 secure airway
 guarantee gas exchange
 stabilize circulation
 ICP management protocols
 Prevent hypoxia, hypotension
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6. Nursing management
•
•
•
•
•
•
 cranial blood or CSF volume
Osmotic diuretics
Systemic diuretics
Monitor electrolytes, urine output
Medication: dexamethasone, histamine
Posture position
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7. CPP = MAP - ICP
CPP = 70 - 100 mmHg
MAP = 50 - 150 mmHg
ICP = 5 - 20 mmHg
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8. The postoperative patients in the
first 24 hours  CBF  50%
Head-injured patient after surgery:
CPP should be kept 70 mmHg
MAP should be kept 80-90 mmHg
(Moppett, 2007)

9. Classic signs of  ICP
“Cushing’s triad”
•  SBP
• Widening PP
• Bradycardia with a full bounding pulse
• Rapid or irregular respiration
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10. Late signs of  ICP
•
•
•
•
•
•
Restlessness, then apparent calm
Deeping stupor and  LOC
Headache and  intensity
Projectile vomiting
Unequal size of pupils, abnormal reaction
Widening PP, slow bound pulse

11. Score for comatose patient
Glasgow Coma Score
(GCS) : 15 points
Full Outline of
UnResponsiveness
(FOUR) : 16 points
• Eye response
• Eye response
• Motor response
• Motor response
• Verbal response
• Brain stem reflexes
• Respiration
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12. FOUR Scale
Eye response
4 Eyelids open/opened, tracking, or blink to command
3 Eyelids open but with no tracking
2 Eyelids are closed but open to loud voices
1 Eyelids are closed but open to pain
0 Eyelids remain closed with pain
Motor response
4 Thumb –up, fist, or peace sign
3 Localized pain
2 Flexion response to pain
1 Extension response to pain
0 No response to pain or generalized myodonous status
Brainstem Reflex
4 Pupil and corneal reflexes present
3 One pupil wide and fixed
2 Pupil or corneal reflexes absent
1 Pupil and corneal reflexes absent
0 Absent pupil, corneal, and cough reflex
Respiration
4 Not intubated, regular breathing pattern
3 Not intubated, cheyne-strokes breathing pattern
2 Not intubated, irregular breathing
1 Breathes above ventilator rate
0 Breathes at ventilator rate or apnea
Glasgow coma scale
Eye opening
4 Spontaneous eye opening
3 Eye opening to speech
2 Eye opening to pain
1 No reaction to pain
Best motor response
6 Obeying commands
5 Localization to pain
4 Normal flexion to pain
3 Abnormal flexion to pain
2 Extension to pain
1 No response to pain
Best verbal response
5 Oriented
4 Confused conversation
3 Inappropriate words
2 Incomprehensible sounds
1 No response

13. Severity of injuries
Mild
Moderate
Severe
head injury
head injury
head injury
• GCS = 13-15
• GCS = 9-12
• associated with
• associated with
• GCS less than
or equal to 8
loss of
a loss of
consciousness
consciousness
loss of
or amnesia for
for up to a day
consciousness
less
for more than
24 hours
• than 1 hour
FOUR scale 15-16
• associated with
FOUR scale 8-14
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FOUR scale 0-7

14. 1 point  Four score
 mortality reduce 36%
 poor function outcome reduce 29%
 poor neurological outcome reduce 33%
Sadaka, et al., 2012

15. Nursing management
• Adequate oxygenation, perfusion, CPP
• Osmotherapy
• Prepare for surgical intervention
• Pharmacologic agent ;  ICP,  cerebral edema
• Close monitoring
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16. Severe TBI (GCS = 3-8)
 obtain CT brain
 secondary insult; hypotension, hypoxia
1survey &
resuscitation
Airway & breathing
 Assisting in ET intubation
 Monitoring blood gas
 Monitoring O2 sat
Circulation
 Volume deplacement
 Assisting in FAST, DPL
 IV fluid
 Monitor : V/S, LOC
Neurological
examination
 Assess GCS, pupil,
motor response
 Monitor : V/S, N/S, GCS
Re-assess
Record & repot
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2survey &
management
 Assess GCS, pupil
reaction, lateralization,
 Assess herniation
 Repeated CT scan
 Assisting in diagnostic
test, surgical tratment

17. Medication therapy
 Intravenous fluids
 Maintain volume
 Prevent hypovolemia
 Should not use hypotonic fluids
 Monitor serum Na+ level
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18. Medication therapy
 Hyperventilation
  PaCO2
 Normocarbia
 keep PaCO2 at 35 mmHg
 For acute neurologic deterioration;
keep PaCO2 at 25-35 mmHg
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19. Medication therapy
 Mannitol
  elevate intracranial pressure
 Usually use 20% IV, 1 g/kg
 acute neurologic deterioration;
bolus mannitol 1 g/kg rapidly > 5 min,
then CT brain
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20. Medication therapy
 Furosamide
 Conjunction use with mannitol
 Usually use 0.3-0.5 mg/kg IV
 Steroids
 Control  ICP
 Improve severe brain injury

21. Medication therapy
 Barbitulates
  ICP
 Not indicated in the acute
resuscitative phase
 Anticonvulsants
 100 mg/8 hours,
1 gm.IV rate < 50mg/min
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22. Injury
First hit: Tissue injury
Shock
Host response:
- Local pro-inflammatory
- Local anti-inflammatory
Tissue
hypoperfusion
Primed inflammatory
system
Tissue ischemia
/hypoxia
Endothelial
dysfunction
Activation of complement,
coagulation, inflammatory cascades
Uncontrolled
inflammatory response
SIRS
Inadequate resuscitate
MODS
Renal dysfunction
Hematologic dysfunction
Urden, et al., 2010; Deitch, Vincent & Windsor, 2002

23. Multiple Organ Dysfunction Score
Marshall,J.C.(2003) ACS Surgery : Principle and Practice
Organ
indicator
none
minimal
mild
moderate
severe
Respiratory
PaO2/FiO2
ratio
> 300
226-300
151-225
76-150
≤ 75
Renal
Serum
creatinine
(umol/L)
≤ 100
101-200
201-350
351-500
> 500
Hepatic
Serum
birirubin
(umol/L)
≤ 20
21-60
61-120
121-240
> 240
Cardiovascular
CVP/MAP
< 10.0
10.115.0
15.1-20.0
20.1-30.0
> 30.0
Hematologic
Platelet
count
(mm3)
>
120,000
81,000120,000
51,00080,000
21,00050,000
≤ 20,000
Neurologic
GCS
15
13-14
10-12
7-9
≤6

24. Denver Postinjury
Multiple organ Failure Score (Moore)
Dysfunction
0
1
2
3
Pulmonary PaO2/FiO2
>208
208-165
165-83
<83
Renal
Creatinine (umol/l)
>159
160-210
211-420
>420
Hepatic
Total Birilubin (umol/l)
<34
34-68
69-137
>137
No inotropes
Only one
inotrope at a
small dose
Any inotrope at
moderate dose
or >1 agent,
all at small
dose
Any inotrope at
large dose
or >2 agents,
at moderate
dose
Cardiac
Inotropes
• ISS >15, survived longer 48 hr,  16 years of age

25. Principle emergency care
of critical patient
 Adequate oxygenation
 Adequate perfusion
 Adequate cerebral perfusion
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26. Alveolar arterial gradient;
(A-a)DO2
(A-a)DO2 = PAO2 - PaO2
Oxygen in alveoli
= PAO2
Arterial oxygen pressure = PaO2
(A-a) DO2 > 20 mmHg = O2 deficiency
(Hennessey & Japp, 2007)

27. Alveolar arterial gradient;
(A-a)DO2
(A-a)DO2 = PAO2 - PaO2
= (713 x FiO2) - PaCO2 /0.85
www.globalrph.com/aagrad.cgi
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28. Blood glucose
 aerobic metabolism ของกลูโคสให้
พลังงาน 38 ATP แต่ถ้า anaerobic
metabolism จะให้พลังงานเพียง 2 ATP
 ทาให้ Na+ เคลือนเข้าสู่เซลล์ และ K+
่
เคลื่อนออกนอกเซลล์ เกิดการบวมนา
ของเซลล์ และ Ca++ เคลือนเข้าสูเซลล์
่
่
ทาให้เซลล์สูญเสียหน้าที่
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29. Hyperglycemia caused
intracellular osmotic pressure 
Glucose > 200 mg/dl
O2 deficiency
Cerebral ischemia, anaerobic metabolism