The document discusses the evaluation and management of head injury patients. It outlines assessing airway, breathing, circulation, disability level using the Glasgow Coma Scale. Patients undergo imaging with CT based on risk level and are admitted or observed based on findings. Management includes neuro checks, IV fluids, analgesics, and intracranial pressure monitoring if indicated based on severity. Surgical intervention may be needed for specific lesions or increasing intracranial pressure.

1. Head injury management
By Dr Mengistu Kassa GSR III
Moderator-Dr
Yordanos(Neurosurgeon)

2. OUTLINES
• Introduction
• Patient evaluation
• General management of head injury
• ICP management
• Specific lesion management
• Brain death
• Summary
• References
3/22/2021
By Mengistu .K on head
injury
2

3. Objectives
• To discuss on evaluation and management of
head injury patients.
3/22/2021
By Mengistu .K on head
injury
3

4. Introduction
• Brain injury from trauma results from two
distinct processes:
▫ Primary brain injury
▫ Secondary injury
• Fall : common causes of TBI in children
• MVA: common causes of TBI in adults –more
fatal.
• 15% of patients exhibit delayed deterioration
• Most common cause of pediatric traumatic
death.
3/22/2021
By Mengistu .K on head
injury
4

5. • Differences between adult and pediatric head
injury:
▫ Children often have milder injuries than adults
▫ Lower chance of a surgical lesion in a comatose
child than in an adult
▫ There are injuries peculiar to pediatrics
▫ Posttraumatic seizures more likely to occur within
the first 24 hrs in children
3/22/2021
By Mengistu .K on head
injury
5

6. Patient evaluation
• ABCDs of life —must be assessed and stabilized
first.
• Secure the airway (usually by endotracheal
intubation)
▫ Depressed level of consciousness usually GCS ≤ 7
▫ Need for hyperventilation
▫ Severe maxillofacial trauma
▫ Need for pharmacologic paralysis for evaluation or
management
3/22/2021
By Mengistu .K on head
injury
6

7. • Hypoxia :PaO2 <60 mm Hg on ABG in combination
with hypotension triples mortality and increases the
risk of bad outcome
• Hypotension (SBP < 90 mm Hg) is rarely
attributable to head injury except:
▫ In terminal stages and in case of exsanguination
▫ In infancy, where enough blood can be lost
intracranially or into the subgaleal space to cause
shock
▫ Doubles mortality
3/22/2021
By Mengistu .K on head
injury
7

8. • Mental status
3/22/2021
By Mengistu .K on head
injury
8

9. • History
▫ Determine mechanism.
▫ Assess for seizures and loss of consciousness
▫ Current headache, stable, increasing or decreasing
▫ Nausea or vomiting
▫ Any history of bleeding disorders and other past
medical history
3/22/2021
By Mengistu .K on head
injury
9

10. Physical examination
• Visual inspection of cranium:
• Evidence of basal skull fracture (Raccoon’s eyes,
battle’s sign ,CSF rhinorrhea/ otorrhea and
hemotympanum)
• Check for facial fractures
• Periorbital edema, proptosis
• Cranio-cervical auscultation
• Auscultate over carotid arteries
• Auscultate over globe of eye
• Physical signs of trauma to spine
• Evidence of seizure
3/22/2021
By Mengistu .K on head
injury
10

11. Neurologic exam
• Cranial nerve exam
▫ optic nerve function
▫ Pupil size and reaction to light
▫ Check for peripheral CN VII and abducens palsy
• Level of consciousness/mental status
▫ Glasgow coma scale
▫ Check orientation in patient able to communicate
3/22/2021
By Mengistu .K on head
injury
11

12. • Motor exam (assesses motor tracts from motor
cortex through spinal cord)
• Sensory exam
▫ Cooperative patient: check pinprick on trunk and in all
4 extremities, touch on major dermatomes
▫ Uncooperative patient: check for central response to
noxious stimulus
3/22/2021
By Mengistu .K on head
injury
12

13. • Reflexes
• Muscle stretch (“deep tendon”) reflexes
• Plantar reflex for upgoing toes (Babinski sign)
• In suspected spinal cord injury: the anal wink and
bulbocavernosus reflex
3/22/2021
By Mengistu .K on head
injury
13

14. 3/22/2021
By Mengistu .K on head
injury
14

15. Indications for CT and admission
criteria for TBI
3/22/2021
By Mengistu .K on head
injury
15
•Category 1. Low risk for intracranial injury

16. • Category 2. Moderate risk for intracranial injury
▫ Head CT scan (unenhanced)
▫ Observation at home, if the patient meets the criteria or in-
hospital, if pt doesn’t meet the criteria
▫ SXR not recommended unless CT scan is not available.
3/22/2021
By Mengistu .K on head
injury
16

17. • Category 3. High risk for intracranial injury
▫ Admit to hospital
▫ Start unenhanced head CT scan
▫ If there are focal findings on neurologic examination:
notify operating room to be on standby and if CTscan or
MRI is not available, consider exploratory burr holes
▫ Determine if intracranial monitor is indicated
3/22/2021
By Mengistu .K on head
injury
17

18. Indications for initial brain CT
• Presence of any moderate or high risk criteria
• Assessment prior to general anesthesia for other
procedures
• Urgent follow-up CT:
▫ Loss of 2 or more points on the GCS
▫ Development of hemiparesis or new pupillary
asymmetry
▫ Persistent vomiting
▫ Worsening H/A
▫ Seizures or unexplained rise in intracranial pressure
3/22/2021
By Mengistu .K on head
injury
18

19. Admitting orders for head injury
• Activity: BR with HOB elevated 30–45°
• Neuro checks q 2 hrs. Contact physician for
neurologic deterioration
• NPO until alert; then clear liquids, advance as
tolerated
• Isotonic IVF (e.g. NS+20 mEq KCl/L) run at
maintenance≈ 100 cc/hr for average sized adult.
• Mild analgesics: acetaminophen (PO, or PR if
NPO), codeine if necessary
• Anti-emetic
3/22/2021
By Mengistu .K on head
injury
19

20. • For GCS = 9–12 admit to ICU. For GCS = 13,
admit to ICU if CT shows any significant
abnormality
• For pts with moderate or sever HI keep NPO in
case surgical intervention is needed
Any patient who fails to reach a GCS of 14–15
within 12 hrs should have a repeat CT at that
time.
3/22/2021
By Mengistu .K on head
injury
20

21. 3/22/2021
By Mengistu .K on head
injury
21

22. 3/22/2021
By Mengistu .K on head
injury
22

23. 3/22/2021
By Mengistu .K on head
injury
23

24. 3/22/2021
By Mengistu .K on head
injury
24

25. 3/22/2021
By Mengistu .K on head
injury
25

26. 3/22/2021
By Mengistu .K on head
injury
26

27. 3/22/2021
By Mengistu .K on head
injury
27

28. 3/22/2021
By Mengistu .K on head
injury
28

29. 3/22/2021
By Mengistu .K on head
injury
29

30. 3/22/2021
By Mengistu .K on head
injury
30

31. 3/22/2021
By Mengistu .K on head
injury
31

32. 3/22/2021
By Mengistu .K on head
injury
32

33. 3/22/2021
By Mengistu .K on head
injury
33

34. 3/22/2021
By Mengistu .K on head
injury
34

35. 3/22/2021
By Mengistu .K on head
injury
35

36. 3/22/2021
By Mengistu .K on head
injury
36

37. 3/22/2021
By Mengistu .K on head
injury
37

38. 3/22/2021
By Mengistu .K on head
injury
38

39. 3/22/2021
By Mengistu .K on head
injury
39

40. 3/22/2021
By Mengistu .K on head
injury
40

41. 3/22/2021
By Mengistu .K on head
injury
41

42. 3/22/2021
By Mengistu .K on head
injury
42

43. 3/22/2021
By Mengistu .K on head
injury
43

44. 3/22/2021
By Mengistu .K on head
injury
44

45. 3/22/2021
By Mengistu .K on head
injury
45

46. 3/22/2021
By Mengistu .K on head
injury
46

47. 3/22/2021
By Mengistu .K on head
injury
47

48. 3/22/2021
By Mengistu .K on head
injury
48

49. 3/22/2021
By Mengistu .K on head
injury
49

50. 3/22/2021
By Mengistu .K on head
injury
50

51. 3/22/2021
By Mengistu .K on head
injury
51

52. 3/22/2021
By Mengistu .K on head
injury
52

53. 3/22/2021
By Mengistu .K on head
injury
53

54. 3/22/2021
By Mengistu .K on head
injury
54

55. 3/22/2021
By Mengistu .K on head
injury
55

56. 3/22/2021
By Mengistu .K on head
injury
56

57. 3/22/2021
By Mengistu .K on head
injury
57

58. 3/22/2021
By Mengistu .K on head
injury
58

59. 3/22/2021
By Mengistu .K on head
injury
59

60. 3/22/2021
By Mengistu .K on head
injury
60

61. 3/22/2021
By Mengistu .K on head
injury
61

62. 3/22/2021
By Mengistu .K on head
injury
62