The document provides an overview of evaluating and managing a patient with head injury. It discusses initial assessment according to ATLS guidelines focusing on airway, breathing, and circulation. It also covers neurological assessment including Glasgow Coma Scale and pupil examination. Indications for CT scan and referral to a trauma center are outlined. Management goals include maintaining adequate oxygenation, ventilation, blood pressure, ICP and CPP. Further management may involve therapies such as hyperosmolar treatment, hypothermia, nutrition, antiseizure medications, and antibiotics.

1. EVALUATION OF A PATIENT WITH
HEAD INJURY
DR. BARUN KUMAR

2. Epidemiology
• Estimated 5-10 lakh cases of head injury
every year
• 20% moderate to severe
• 1.5 lakh trauma deaths
• 50% attributable to head trauma

3. Initial assessment
• The initial management is in accordance to
ATLS guidelines.
• A - airway
• B - breathing
• C - circulation

4. Airway
• Manual manoeuvres (chin lift, jaw
thrust,recovery position, etc.)
• Insertion of oral or nasal airway
• Use of suction
• Assisted ventilation using bag–valve–mask
• Endotracheal intubation
• Cricothyroidotomy (with or without
tracheostomy)

5. Airway
• Goals
• Maintain SPO2 > 90%
• Maintain PaO2 > 60mmHg

6. • Indication for intubation
Indication for intubation
Unable to maintain airway
GCS ≤ 8
Loss of protective laryngeal
reflexes
Unstable facial bone #
Bleeding into mouth
Seizures
Ventilatory insufficiency Spontaneous hyperventilation
Irregular respiration

7. Breathing
• Assessment of respiratory distress and
adequacy of ventilation
• Administration of oxygen
• Needle thoracostomy
• Chest tube insertion

8. Circulation
Goals
• Maintain SBP > 90mm of Hg
• Prevention of secondary brain injury

9. Circulation
• IV crystalloid
• Hypotensive resuscitation
• Colloid
• Blood
• Component transfusion

10. • Transport to equipped center
• Prognosis depends on initiation of primary
care
• Enroute management

11. Neurological assessment
• Glasgow coma scale --Quick ,efficient
• Examination of Pupil
• history

13. Classification by clinical severity
• Mild/Minor TBI: GCS 13-15; mortality 0.1%
• Moderate TBI: GCS 9-12; mortality 10%
• Severe TBI: GCS <9; mortality 40%.

14. Pupil
Pupil size:
• The normal diameter of the pupil is between 2
and 5 mm, and although both pupils should be
equal in size,
• a 1-mm difference is considered a normal
variant.
• Abnormal size is noted by anisocoria: >1 mm
difference between pupils

15. Pupil
Pupil symmetry:
• Normal pupils are round, but can be irregular
due to ophthalmological surgeries.
• Abnormal symmetry may result from
compression of CNIII can cause a pupil to initially
become oval before becoming dilated and fixed.

16. Pupil
Direct light reflex:
• Normal pupils constrict briskly in response to light, but
may be poorly responsive due to ophthalmological
medications.
• Abnormal light reflex may be seen in sluggish pupillary
responses are associated with increased ICP
• A non-reactive, fixed pupil has <1 mm response to
bright light and is associated with severely increased
ICP.

17. History
Mechanism of injury and detailed description of the injury
• loss of consciousness, amnesia, lucid periods
• seizures, confusion, deterioration in mental status
• vomiting or headache
Drug or alcohol use
• current intoxication: shown to have an increased association with
intracranial injury detected on CT[89]
• chronic: associated with cerebral atrophy, thought to increase risk of
shearing of bridging veins
• Past medical history, including any CNS surgery, past head trauma,
haemophilia, or seizures
• • Current medications including anticoagulants
• Age: TBI in older age has a poorer outcome in all subgroups

18. Physical examination
Head and neck
• inspection for cranial nerve deficits, periorbital or
postauricular ecchymoses, CSF rhinorrhoea or
otorrhoea,haemotympanum (signs of base of skull fracture)
• fundoscopic examination for retinal haemorrhage (sign of
abuse)[90] and papilloedema (sign of increased
ICP)
• palpation of the scalp for haematoma, crepitance,
laceration, and bony deformity (markers of skull fractures)

19. Physical examination
• auscultation for carotid bruits (sign of carotid
dissection)
• evaluation for cervical spine tenderness,
paraesthesias, incontinence, extremity
weakness, priapism (signs of spinal cord injury)
• Extremities should receive motor and sensory
examination (for signs of spinal cord injury)

20. Baseline laboratory investigations should
include:
• CBC including platelets
• serum electrolytes and urea
• serum glucose
• coagulation status: PT, INR, activated PTT
• blood alcohol level and toxicology screening if
indicated

21. Indications for CT scan
• eye opening only to pain or not conversing (GCS
12/15 or less)
• ƒconfusion or drowsiness (GCS 13/15 or 14/15)
followed by failure to improve within
• at most one hour of clinical observation or within
two hours of injury (whether or not intoxication from
drugs or alcohol is a possible contributory factor)
• ƒbase of skull or depressed skull fracture and/or
suspected penetrating injuries

22. Indications for CT scan
• ƒa deteriorating level of consciousness or new
focal neurological signs
• ƒfull consciousness (GCS 15/15) with no fracture
but other features, eg
- severe and persistent headache
- two distinct episodes of vomiting
• ƒa history of coagulopathy (eg warfarin use) and
loss of consciousness, amnesia or any
neurological feature.

23. Referral
• Any evidence of major brain trauma should be
managed at a trauma center and a neurosurgeon.
Indications for referral
• GCS<15 at initial assessment for two hours and
refer if GCS score remains<15 after this time)
• ƒpost-traumatic seizure (generalised or focal)
• ƒfocal neurological signs
• ƒsigns of a skull fracture (including cerebrospinal
fluid from nose or ears,haemotympanum, boggy
haematoma, post auricular or periorbital bruising

24. • ƒloss of consciousness
• ƒsevere and persistent headache
• ƒrepeated vomiting (two or more
occasions)
• ƒpost-traumatic amnesia >5 minutes
• ƒretrograde amnesia >30 minutes
• ƒhigh risk mechanism of injury (road traffic
accident, significant fall)
• ƒcoagulopathy, whether drug-induced or
otherwise.

25. TRAUMATIC BRAIN INJURY
Bone fracture Intracranial
hemorrhage
Diffuse axonal
injury
Open/
closed
Linear/
comminuted
Depressed/
nondepressed
EDH SAH
Intraparenchymal
hemorrhage

26. ASSESSMENT OF INTRACRANIAL
PRESSURE
CPP = MAP – ICP
CPP = cerebral
perfusion pressure
>70mmHg in adult
> 60mmHg in children
ICP= Intracranial pressure Range 5mmHg (infant) to
15mmHg (adult)

27. ASSESSMENT OF INTRACRANIAL
PRESSURE
ICP should be monitored in :
• Severe head trauma (GCS= 3-8 )
• Abnormal CT scan ( hematoma, contusion,
swelling , herniation, compressed basal
cistern)

28. • A ventricular catheter connected to an
external strain gauge transducer
• Alternative- intraparenchymal transducer

29. GOALS
• ICP < 20 mm of Hg
• CPP > 70 mm of Hg ( < 50 is critical )

30. FURTHER MANAGEMENT
• HYPOXIA
• HYPEROSMOLAR THERAPY
• HYPOTHERMIA
• NUTRITION
• ANTISEIZURE
• HYPERVENTILLATION
• ANTIBIOTICS
• ANALGESIA

31. Refrences
1. Sabiston textbook of surgery 19th edition
2. Bailey & love’s short practice of surgery 26th ed
3. BMJ, best practice assessment of head trauma, acute
4. Guidelines for the management of severe traumatic brain injury –
BRAIN TRAUMA FOUNDATION
5.GUIDELINES FOR ESSENTIAL TRAUMA CARE World Health
Organization Avenue Appia 201211 Geneva 27
6.NICE guidelines head injury
7.The Brain Trauma Foundation. Prehospital Emergency Care
8.The Brain Trauma Foundation. Early indicators of Prognosis in Severe
Traumatic Brain Injury.
9.The Brain Trauma Foundation. Surgical Management of TBI Author
Group.

32. Thank you