4 million people experience head trauma annually, with severe head injury being a leading cause of trauma death. Timely treatment is critical to prevent increased intracranial pressure from hemorrhages or edema, which can cause permanent brain damage or death. Signs of increased ICP include changes in vital signs, pupil reactivity, eye movements, muscle tone, and level of consciousness on the Glasgow Coma Scale. Early interventions like oxygen supplementation, ventilation support, and maintaining normal blood pressure and carbon dioxide levels are important to preserve brain perfusion and prevent further neurological injury.

1. Common major trauma
4 million people experience head trauma
annually
 Severe head injury is most frequent cause of trauma death
At Risk population
 Males 15-24 years
 Infants
 Young Children
 Elderly
INTRODUCTION TO HEAD
INJURIES

2. TIME IS CRITICAL
 Intracranial Hemorrhage
 Progressing Edema
 Increased ICP
 Cerebral Hypoxia
 Permanent Damage
Severity is difficult to recognize
 Subtle signs
 Improve differential diagnosis
 Improves survivability
INTRODUCTION TO HEAD
INJURIES

3. Mechanism of Injury
 Blunt Injury
 Motor vehicle collisions
 Assaults
 Falls
 Penetrating Injury
 Gunshot wounds
 Stabbing
 Explosions
PATHOPHYSIOLOGY OF
HEAD INJURY

4. Head Injury
Cranial Injury
Brain Injury
DIFFERENT TYPES OF INJURY

5. HEAD INJURY
Open
• Skull compromised
and brain exposed
Closed
• Skull not compromised
and brain not exposed
5Head Trauma -

6. Contusions
Lacerations
Avulsions
Significant Hemorrhage
SCALP INJURY

7. HEAD INJURIES
Scalp wound
• Highly vascular, bleeds briskly
 Shock: child may develop
 Shock: adult another cause
• Management
 No unstable fracture:
direct pressure, dressings
 Unstable fracture: dressings, avoid direct pressure
7Head Trauma -

8. Skull fracture
• Linear nondisplaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Management
• Dressing, avoid excess pressure
HEAD INJURIES
8Head Trauma -

9. Trauma must be extreme to fracture
 Linear
 Depressed
 Open
 Impaled Object
CRANIAL INJURY

10. Basal Skull
 Unprotected
 Spaces weaken
structure
 Relatively
easier to fracture

11. Basal Skull Fracture Signs
 Battle’s Signs
 Retroauricular Ecchymosis
 Associated with fracture of
auditory canal and lower
areas of skull
 Raccoon Eyes
 Bilateral Periorbital
Ecchymosis
 Associated with orbital
fractures
CRANIAL INJURY

12. BASILAR SKULL FRACTURE
Battle’s sign Raccoon eyes
12Head Trauma -

13. Basilar Skull Fracture
 May tear dura
 Permit CSF to drain through an
external passageway
 May mediate rise of ICP
 Evaluate for “Target” or “Halo” sign
CRANIAL INJURY

14. CRAINIAL INJURIES
Penetrating trauma
14Head Trauma -
Bullet fragments

15. Head Trauma - 15
Forces that cause skull fracture
can also cause brain injury.

16. As defined by the National Head Injury Foundation
 “a traumatic insult to the brain capable of producing physical,
intellectual, emotional, social and vocational changes.”
BRAIN INJURY

17. BRAIN INJURY
Response to injury
• Swelling of brain
 Vasodilatation with increased blood volume
 Increased ICP
• Decreased blood flow to brain
 Perfusion decreases
 Cerebral ischemia (hypoxia)
17Head Trauma -

18. Altered Mental Status
 Altered orientation
 Alteration in personality
 Amnesia
 Retrograde
 Antegrade
Cushing’s Reflex
 Increased BP
 Bradycardia
 Erratic respirations
SIGNS & SYMPTOMS
OF BRAIN INJURY
 Vomiting
 Without nausea
 Projectile
 Body temperature
changes
 Changes in pupil
reactivity
 Decorticate
posturing

19. Pathophysiology of Changes
 Frontal Lobe Injury
 Alterations in personality
 Occipital Lobe Injury
 Visual disturbances
 Cortical Disruption
 Reduce mental status or Amnesia
 Retrograde
 Unable to recall events before injury
 Antegrade
 Unable to recall events after trauma
 “Repetitive Questioning”
 Focal Deficits
 Hemiplegia, Weakness or Seizures
SIGNS & SYMPTOMS
OF BRAIN INJURY

20. Classification
Direct
Primary injury caused by forces of trauma
Indirect
Secondary injury caused by factors resulting from the
primary injury

21. BRAIN INJURY
Direct brain injury
• Immediate damage
due to force
• Coup and contracoup
• Fixed at time of injury
Management
• Directed at prevention
21Head Trauma -

22. Coup
 Injury at site of impact
Contrecoup
 Injury on opposite side
from impact
DIRECT BRAIN INJURY TYPES

23. BRAIN INJURY
Indirect brain injury
• Results from hypoxia
or decreased perfusion
• Response to primary injury
• Develops over hours
Management
• Good prehospital care can help prevent
23Head Trauma -

24. Focal
 Occur at a specific location in brain
 Differentials
 Cerebral Contusion
 Intracranial Hemorrhage
 Epidural hematoma
 Subdural hematoma
 Intracerebral Hemorrhage
Diffuse
 Concussion
 Moderate Diffuse Axonal Injury
 Severe Diffuse Axonal Injury
DIRECT BRAIN INJURY
CATEGORIES

25. Cerebral Contusion
 Blunt trauma to local brain tissue
 Capillary bleeding into brain tissue
 Common with blunt head trauma
 Confusion
 Neurologic deficit
 Personality changes
 Vision changes
 Speech changes
 Results from
 Coup-contrecoup injury
FOCAL BRAIN INJURY

26. BRAIN INJURIES
Cerebral contusion
• Bruising of brain tissue
 Swelling may be rapid and severe
• Level of consciousness
 Prolonged unconsciousness,
profound confusion or amnesia
• Associated symptoms
 Focal neurological signs
 May have personality changes
26Head Trauma -

27. Epidural Hematoma
 Bleeding between dura mater
and skull
 Involves arteries
 Middle meningeal artery most
common
 Rapid bleeding & reduction of
oxygen to tissues
 Herniates brain toward foramen
magnum
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE

28. INTRACRANIAL
HEMORRHAGE
Acute epidural hematoma
• Arterial bleed
 Temporal fracture common
 Onset: minutes to hours
• Level of consciousness
 Initial loss of consciousness
 “Lucid interval” follows
• Associated symptoms
 Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral
paralysis, death
28Head Trauma -

29. Subdural Hematoma
 Bleeding within meninges
 Beneath dura mater & within subarachnoid
space
 Above pia mater
 Slow bleeding
 Superior sagital sinus
 Signs progress over several days
 Slow deterioration of mentation
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE

30. INTRACRANIAL
HEMORRHAGE
Acute subdural hematoma
• Venous bleed
 Onset: hours to days
• Level of consciousness
 Fluctuations
• Associated symptoms
 Headache
 Focal neurologic signs
• High-risk
 Alcoholics, elderly, taking anticoagulants
30Head Trauma -

31. INTRACRANIAL
HEMORRHAGE
Intracerebral hemorrhage
• Arterial or venous
 Surgery is often not helpful
• Level of consciousness
 Alterations common
• Associated symptoms
 Varies with region and degree
 Pattern similar to stroke
 Headache and vomiting
31Head Trauma -

32. Intracerebral Hemorrhage
 Rupture blood vessel within the brain
 Presentation similar to stroke symptoms
 Signs and symptoms worsen over time
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE

33. Due to stretching forces placed on individual nerve cells
Pathology distributed throughout brain
Types
 Concussion
 Moderate Diffuse Axonal Injury
 Severe Diffuse Axonal Injury
DIFFUSE BRAIN INJURY

34. Mild to moderate form of Diffuse Axonal Injury
(DAI)
 Nerve dysfunction without anatomic damage
Transient episode of
 Confusion, Disorientation, Event amnesia
Suspect if patient has a momentary loss of
consciousness
Management
 Frequent reassessment of mentation
 ABC’s
DIFFUSE BRAIN INJURY
CONCUSSION

35. BRAIN INJURIES
Concussion
• No structural injury to brain
• Level of consciousness
 Variable period of unconsciousness or confusion
 Followed by return to normal consciousness
• Retrograde short-term amnesia
 May repeat questions over and over
• Associated symptoms
 Dizziness, headache, ringing in ears, and/or nausea
35Head Trauma -

36. “Classic Concussion”
Same mechanism as concussion
 Additional: Minute bruising of brain tissue
Unconsciousness
May exist with a basilar skull fracture
Signs & Symptoms
 Unconsciousness or Persistent confusion
 Loss of concentration, disorientation
 Retrograde & Antegrade amnesia
 Visual and sensory disturbances
 Mood or Personality changes
DIFFUSE BRAIN INJURY
MODERATE DIFFUSE AXONAL
INJURY

37. BRAIN INJURIES
Diffuse axonal injury
• Diffuse injury
 Generalized edema
 No structural lesion
 Most common injury from
severe blunt head trauma
• Associated symptoms
 Unconscious
 No focal deficits
37Head Trauma -

38. Brainstem Injury
Significant mechanical disruption of nerve
cells
 Cerebral hemispheres and brainstem
High mortality rate
Signs & Symptoms
 Prolonged unconsciousness
 Cushing’s reflex
 Decorticate or Decerebrate posturing
DIFFUSE BRAIN INJURY
SEVERE DIFFUSE AXONAL
INJURY

39. BRAIN ANATOMY
Intracranial volume
• Brain
• CSF
• Blood vessel volume
 Dilatation with high pCO2
 Constriction with low pCO2
 Slight effect on volume
39Head Trauma -

40. Cranial volume fixed
 80% = Cerebrum, cerebellum & brainstem
 12% = Blood vessels & blood
 8% = CSF
 Increase in size of one component diminishes size of another
 Inability to adjust = increased ICP
INTRACRANIAL PERFUSION

41. Compensating for Pressure
 Compress venous blood vessels
 Reduction in free CSF
 Pushed into spinal cord
Decompensating for Pressure
 Increase in ICP
 Rise in systemic BP to perfuse brain
 Further increase of ICP
INTRACRANIAL PERFUSION
ICP BP

42. Vasculature Constriction
Cerebral Edema
Systolic Blood Pressure
 Low BP = Poor Cerebral Perfusion
 High BP = Increased ICP
Carbon Dioxide
Reduced respiratory efficiency
FACTORS AFFECTING ICP

43. Role of Carbon Dioxide
 Increase of CO2 in CSF
 Cerebral Vasodilation
 Encourage blood flow
 Reduce hypercarbia
 Reduce hypoxia
 Contributes to  ICP
 Reduced levels of CO2 in CSF
 Cerebral vasoconstriction
 Results in cerebral anoxia
INTRACRANIAL PRESSURE

45. Increased pressure
 Compresses brain tissue
 Herniates brainstem
 Compromises blood supply
 Signs & Symptoms
 Upper Brainstem
 Vomiting
 Altered mental status
 Pupillary dilation
 Medulla Oblongata
 Respiratory
 Cardiovascular
 Blood Pressure disturbances
PRESSURE & STRUCTURAL DISPLACEMENT

46. Upper Brainstem Compression
 Increasing blood pressure
 Reflex bradycardia
 Vagus nerve stimulation
 Cheyne-Stokes respirations
 Pupils become small and reactive
 Decorticate posturing
 Neural pathway disruption
SIGNS & SYMPTOMS OF BRAIN INJURY
PHYSIOLOGICAL CHANGES

47. Middle Brainstem Compression
 Widening pulse pressure
 Increasing bradycardia
 CNS Hyperventilation
 Deep and Rapid
 Bilateral pupil sluggishness or inactivity
 Decerebrate posturing
SIGNS & SYMPTOMS OF BRAIN INJURY
PHYSIOLOGICAL CHANGES

48. Lower Brainstem Injury
 Pupils dilated and unreactive
 Ataxic respirations
 Erratic with no pattern
 Irregular and erratic pulse rate
 ECG Changes
 Hypotension
 Loss of response to painful stimuli
SIGNS & SYMPTOMS OF BRAIN INJURY
PHYSIOLOGICAL CHANGES

49. Physiological Issues
 Indicate pressure on
 CN-III (Oculomotor Nerve)
 Pressure on nerve causes eyes to be sluggish, then dilated, and finally fixed
 Reduced peripheral blood flow
Pupil Size & Reactivity
 Reduced Pupillary Responsiveness
 Depressant drugs or Cerebral Hypoxia
 Fixed & Dilated
 Extreme Hypoxia
SIGNS & SYMPTOMS OF BRAIN INJURY
EYE SIGNS

50. HEAD TRAUMA ASSESSMENT
Initial Assessment
Rapid Trauma Exam
Limit patient agitation, straining
• Contributes to elevated ICP
Airway
• Vomiting very common within first hour
• Endotracheal intubation
50Head Trauma -

51. Head Trauma - 51
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.

52.  Reactive: ICP increasing
 Nonreactive (altered LOC):
increased ICP
 Nonreactive (normal LOC): not
from head injury
PUPILS
Both dilated
 Nonreactive: brainstem
 Reactive: often reversible
Unilaterally dilated
52Head Trauma -
Eyelid closure
• Slow: cranial nerve III
• Fluttering: often hysteria
Anisocoria

53. GLASGOW COMA SCALE
Suspect severe brain injury GCS <9
53Head Trauma -
*Decorticate posturing to pain
**Decerebrate posturing to pain

54. EXTREMITY POSTURING
Decorticate
• Arms flexed
and legs extended
Decerebrate
• Arms extended
and legs extended
54Head Trauma -

55. INCREASING ICP
55Head Trauma -
Vital Sign Change with Increasing ICP
Respiration Increase, decrease, irregular
Pulse Decrease
BP Increase, widening pulse
pressure
Cushing’s response
• As ICP increases, systolic BP increases
• As systolic BP increases, pulse rate decreases

56. Head Trauma - 56
Early efforts
to maintain brain perfusion
can be life-saving.

57. THE INJURED BRAIN
Hypoxia
• Perfusion decrease causes cerebral ischemia
• Hyperventilation increases hypoxia
significantly more than it decreases ICP
Assist ventilation
• High-flow oxygen
• One breath every 6–8 seconds
• SpO2 >95%
• Maintain EtCO2 at 35 mmHg
57Head Trauma -

58. THE INJURED BRAIN
Hypotension
• Single instance increases mortality
 Adult (systolic <90 mmHg) 150%
 Child (systolic < age appropriate) worse
Fluid administration for traumatic brain injury, GCS <9
• Titrate to 110–120 mmHg systolic
with or without penetrating hemorrhage
to maintain CPP
58Head Trauma -

59. THE INJURED BRAIN
Cerebral herniation syndrome
• Brain forced downward
 CSF flow obstructed, pressure on brainstem
• Level of consciousness
 Decreasing, rapid progression to coma
• Associated symptoms
 Ipsilateral pupil dilatation, out-downward deviation
 Contralateral paralysis or decerebrate posturing
 Respiratory arrest, death
59Head Trauma -

60. CEREBRAL HERNIATION
Is ICP severe enough
to outweigh cerebral ischemia?
60Head Trauma -

61. HYPERVENTILATION
Cerebral herniation syndrome
• Herniation danger outweighs hypoxia
Indications for hyperventilation
• TBI GCS <9 with decerebrate posturing
• TBI GCS <9 with dilated or nonreactive pupils
• TBI initial GCS <9, then drops >2 points
If signs resolve, stop hyperventilation.
61Head Trauma -

62. HYPERVENTILATION RATES
Capnography
• Maintain EtCO2 <30 mmHg, but >25 mmHg
62Head Trauma -
Age Group Normal Rate Hyperventilatio
n
Adult 8–10 per minute 20 per minute
Children 15 per minute 25 per minute
Infants 20 per minute 30 per minute

63. THANK YOU