This document discusses the management of head injuries. It begins with an overview of head injury epidemiology and mechanisms. It then covers the anatomy of the head, intracranial physiology including intracranial pressure, classifications of head injuries, imaging, and medical and surgical management approaches. Key aspects of management include stabilizing the patient's airway, breathing, and circulation, performing neurological assessments, obtaining imaging studies like CT scans, treating elevated intracranial pressure medically with interventions like mannitol and hyperventilation, and surgically evacuating hematomas if needed. The goal is to prevent secondary brain injury through aggressive resuscitation and controlling intracranial factors.

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Head injury
Dr. B.Padmashini
Department of Accident, Emergency & Critical Care Medicine.
Vinayaka Mission Kirupananda Variyar Medical College & Hospital.
Salem,Tamil Nadu

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Head Injury
• Number One Killer in
Trauma
• 25% of all trauma deaths
• 50% of all deaths from MVC
• 200,000 people in the world
live with the disability
caused by these injuries

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Road Traffic Crashes

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Sports injuries

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Assaults
(Sickle injuries)

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Basic Anatomy
• Scalp
• Skull
• Meninges
– Dura Mater
– Arachnoid
– Pia Mater
• Brain Tissue
• CSF and Blood

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Skull

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Dura-
mater

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Venous
sinuses

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Arachnoid
mater

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Pia-
mater

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CSF

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Grey
matter

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White
matter

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Ventricles

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Intracranial Volume
• 80%
Brain Matter
• 10%
Blood
• 10%
CSF

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The MONROE KELLIE doctrine
Dictates that “the
total volume of the
intracranial
contents MUST
remain constant”

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Normal state- ICP normal

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Compensated state- ICP
normal

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Uncompensated state- ICP
Elevated
75 ml 75 ml

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Volume-Pressure Curve

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Intracranial Pressure
• The pressure of the brain contents within the skull is
intracranial pressure (ICP)
• The pressure of the blood flowing through the brain is
referred to as the cerebral perfusion pressure (CPP)
The pressure of the blood in the body is the mean
arterial pressure (MAP)
CEREBRAL BLOOD FLOW
Normal CBF – 50ml/100gm of brain/min
“AUTOREGULATION”

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ROLE OF
INTRACRANIAL PRESSURE
• 10 mmHg - Normal
• > 20mmHg - Abnormal
• > 40mmHg - Severe
•  ICP  deteriorates brain function
 poor outcome

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Intracranial Pressure
• Cerebral Perfusion Pressure (CPP) can be
determined by the following formula:
CPP = MAP - ICP
• Normal CPP range is 60 - 150 for autoregulation to
work well!

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SYMPTOMS & SIGNS OF
INCREASED ICP
• Diminishing level of consciousness
• Headache, vomiting, seizures
• Cushing’s Triad –
 bradycardia
 hypertension
 abnormal respiration
• Pupillary changes
• Papilledema

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• Primary Injury
• Mechanical irreversible damage - brain lacerations,
hemorrhages, contusions, and tissue avulsions,
• Microscopy - primary injury causes permanent
mechanical cellular disruption and microvascular
injury.
PATHOPHYSIOLOGY

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Secondary Injury
• Neurologic outcome after head trauma - degree of secondary
brain injury.
• Common Secondary systemic insults –
Hypotension – SBP < 90
Hypoxia - Po2 less than 60
Anemia – reduces O2 Carrying capacity of the blood, to the
injured brain tissue,
• Other causes - hypercarbia, hyperthermia, coagulopathy, and
seizures.

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morphology
severity
mechanism
CLASSIFICATION

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MECHANISM
• BLUNT INJURY
 High Velocity
 Low Velocity
• PENETRATING
INJURY
 Gunshot
 Sharp instruments

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Severity -GLASGOW COMA SCALE
ASSESSMENT AREAS SCORE
Eye opening
Best Motor Response
Verbal Response
Total
4
6
5
15
Mild - GCS 13 - 15
Moderate - GCS 9 - 12
Severe - GCS 3 - 8

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MORPHOLOGY
• SCALP INJURY
 Cephal Hematoma
 Subgaleal Hematoma

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• SKULL FRACTURES
• Vault : linear/stellate
depressed/non depressed
open/closed

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Basilar : with/with out CSF leak
with/with out seventh-nerve palsy
Battle sign Raccoon eyes CSF
rhinorrhea

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INTRACRANIAL LESIONS
• Focal : epidural hematoma
subdural hematoma
intracerebral hematoma

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Epidural haematoma
• Collection of blood & clot b/n dura matter and bones
of the skull
• Source Middle Meningeal Artery
Dural Venous Sinuses
• C/F Brief loss of consciousness,
headache,drowsiness,dizzy,nausea,vomitting
• Rapid clinical deterioration
• Talk & die

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EDH

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• Subdural hematomas
• Most frequently from
tearing of a bridging vein
between the cerebral
cortex and a draining
venous sinus.
• - acute - <24hrs
- subacute – 24hrs-2wks
- chronic - >2wks
SDH
Shape-
Crescent

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Intra Cerebral Heamatoma
• Formed within brain tissue & caused by shearing or
tensile forces that mechanically stretch and tear deep
small caliber arterioles
• Most common in temporal and frontal regions
• C/F depend on site involved

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INTRACRANIAL LESIONS
Diffuse : concussion
multiple contusion
hypoxic/ischemic injury

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Concussion
• Temporary & brief interruption of neurological
function after minor head injury
• Due to shearing / stretching of white matter fibres at
the time of impact or temporary neuronal dysfunction
• C/o headache, confusion, amnesia
• CT/MRI cannot detect

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DAI
• Shearing forces disrupt
the axonal fibres in the
white matter
• Shaken baby syndrome
• Blunt trauma
• Rapid rise in ICT.
• Prolonged or
permanent.

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APPROACH TO A PATIENT WITH
HEAD INJURY
• History
• Initial Assessment
 Primary Survey
 Secondary Survey

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PRIMARY SURVEY
Airway maintenance with cervical spine protection

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• Breathing and ventilation : Intubation precautions
Pre-medicate with Lidocaine, 1mg/kg IV 2 minutes
prior to attempt
• Laryngoscopy produces an ICP Spike
Intubation with Cervical inline
stabilization

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Circulation
• Maintain MAP >90mmhg- adequate
• Hematocrit >30%
• Cushing reflex

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• Isolated intracranial injuries do not cause hypotension
• LOOK FOR THE CAUSE OF HYPOTENSION

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Disability
• Pupil size
•GCS
Pupillary Changes
Irregular shaped
Equality?
Constricted?
Dilated?
Vision Problems?

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SECONDARY SURVEY
• AMPLE history
• Examination of Head to toe
• Glasgow Coma Scale
• Detailed Neurological Examination

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IMAGING STUDIES ONLY AFTER
HEMODYNAMIC STABILIZATION

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MANAGEMENT OF
MILD HEAD INJURY(GCS13 -15)
• History
• General Examination
• Limited Neurologic Examination
• C-spine and other X-rays as indicated
• CT scan

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CRITERIA FOR ADMISSION
• No CT scanner available
• Abnormal CT scan findings
• All penetrating head injuries
• Skull fractures
• CSF leak
• Deteriorating level of consciousness
• Moderate to severe headache
• Significant alcohol / drug intoxication
• Significant associated injuries

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INDICATIONS FOR CT SCAN
• Skull fracture
• Deteriorating GCS
• Neurologic deficit
• Amnesia, headache
• Seizure

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MANAGEMENT OF MODERATE
HEAD INJURY(GCS 9-12)
• Initial Examination
- Same as for mild head injury
- CT scan brain – obtained in all cases
- Admission for observation
• After Admission
Frequent Neurologic Checks
Improved Deteriorates (10%)
• Discharge
• Follow up
• Repeat CT scan
• Manage as per severe
head injury protocol

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MANAGEMENT OF SEVERE HEAD
INJURY(3 - 8 )
• Primary Survey and Resuscitation
• Secondary Survey and ‘AMPLE’ history
• Admit to facility – neurosurgical care
• Neurologic Re-evaluation
– Eye opening
– Motor response
– Verbal response
– Pupillary reaction

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• CT scan only after hemodynamic stabilization
• Medical therapy for raised ICP
• Immediate neurosurgeon opinion
• If needed surgical management

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• Head end elevation – 30 deg
• Intravenous fluids:
• Maintain normovolemia
• Hypotonic/glucose containing fluids
should not be used
• Serum sodium levels monitored daily
MEDICAL THERAPIES FOR HEAD
INJURY

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Mannitol
• 0.25-1g/kg
• Osmotic agent- dec ICP, maintains CBF,CPP and brain
metabolism
• Dec ICP within 6 hrs.
• Expands volume, O2 carrying capacity.
• Diuretic effect- net intravascular volume is reduced.

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Furosemide
• To reduce ICT in conjunction with mannitol
• Dose 0.3 to 0.5 mg/kg
• Never use in Hypovolemia

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HYPERVENTILATION
• No role as prophylaxis in 24 hrs.
• Reducing PaCO2 cerebral vasoconstriction
• Maintain PaCo2 25 – 35 mmhg
• Last resort for reducing ICP
• TEMPORARY MEASURE ONLY.

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Barbiturates
• Effective in reducing ICP – refactory to other
measures
• Not used in presence of hypotension/hypovolemia

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• Anticonvulsants
 Phenytoin-
Loading dose - 18 – 20 mg/kg
Maintenance dose - 100 mg q 8 hrly

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Surgical management
• Scalp wounds cleaning & debridemant
• Elevation of depressed Fractures
• Craniotomy & evacuation of Haematoma
• Cranial decompression for reduction of ICT

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Burr hole evacuation

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SUMMARY
• Endotracheal intubation if GCS < 8
• Moderate hyperventilation
• Treat shock aggressively
• Resuscitate with normal saline or Ringer’sLactate solutions.
• Goal is to achieve a euvolemic state
contd..

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SUMMARY
• Frequent neurological assessment
• Exclude cervical spine injuries
• Transfer all moderate to severe head injured patients if neuro
surgeon is not available at your facility

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