head injury is serious dangerous and life threatening problem if NOT treated in time it takes the life of patient

1. Head InjuryHead Injury
ManagementManagement
Man Bahadur PaudyalMan Bahadur Paudyal
MBBS,TU Teaching HospitalMBBS,TU Teaching Hospital

2. Introduction to Head InjuryIntroduction to Head Injury
 Increase in injury morbidity and mortalityIncrease in injury morbidity and mortality
IndustrializationIndustrialization Increase RTAIncrease RTA
ProblemsProblems
lack of appropriate transportation & facilitieslack of appropriate transportation & facilities
Insufficient trained manpowerInsufficient trained manpower
Underdeveloped trauma care systemsUnderdeveloped trauma care systems
Overall poor infrastructureOverall poor infrastructure
INCIDENCE:INCIDENCE:
132 ~ 430/100,000 per year132 ~ 430/100,000 per year

3. Classification of Head InjuryClassification of Head Injury
 ScalpScalp
 HematomaHematoma LacerationLaceration AvulsionAvulsion
 Skull FractureSkull Fracture
 LinearLinear DepressedDepressed CompoundCompound BasilarBasilar
 Brain InjuryBrain Injury
 ContusionContusion LacerationLaceration PenetratingPenetrating
 Vascular InjuryVascular Injury
 EDHEDH SDHSDH SAHSAH IVHIVH

4. PathophysiologyPathophysiology
Brain injuryBrain injury
PrimaryPrimary injuryinjury::
Direct impactDirect impact
contusion (coup, countercoup)contusion (coup, countercoup) lacerationlaceration
Shearing injuryShearing injury DAIDAI
SecondarySecondary insultsinsults::
Developing intracranial mass lesionsDeveloping intracranial mass lesions
hematoma(EDH, SDH, ICH)hematoma(EDH, SDH, ICH)
cerebral edemacerebral edema
Hypoxic-ischemic cerebral injuryHypoxic-ischemic cerebral injury
hypoxiahypoxia hypercarbiahypercarbia hypotensionhypotension
acidosisacidosis pyrexiapyrexia hyponatremiahyponatremia
vasospasmvasospasm seizureseizure

5. Degree of Head InjuryDegree of Head Injury
 determined by GCS/ LOC@arrivaldetermined by GCS/ LOC@arrival
DegreeDegree GCSGCS LOCLOC
MildMild 13 – 1513 – 15 Relatively normalRelatively normal
ModerateModerate 9 – 129 – 12 Altered LOCAltered LOC
SevereSevere 3 – 83 – 8 ComatoseComatose

6. MONROE-KELLIE DOCTRINEMONROE-KELLIE DOCTRINE
 Non-elastic, enclosed compartment (Skull)Non-elastic, enclosed compartment (Skull)
 Uniform pressure throughout cranial cavityUniform pressure throughout cranial cavity
 Sum of intracranial Volume of blood, brainSum of intracranial Volume of blood, brain
& CSF & other (tumor, hematoma) is& CSF & other (tumor, hematoma) is
constantconstant
 Increase in one component must offset byIncrease in one component must offset by
equal decrease in other component or elseequal decrease in other component or else
pressure will risepressure will rise

7. Guideline: Management ofGuideline: Management of Severe Head InjurySevere Head Injury
IntroductionIntroduction
 formulated by joint initiative of Brain Traumaformulated by joint initiative of Brain Trauma
Foundation, AANS and Joint Section onFoundation, AANS and Joint Section on
Neurotrauma and Critical Care (1995)Neurotrauma and Critical Care (1995)
 Degrees of Certainty:Degrees of Certainty:
 StandardsStandards:: Class I evidence (randomized)Class I evidence (randomized)
 GuidelinesGuidelines:: Class II evidence (prospective)Class II evidence (prospective)
 OptionsOptions:: Class III evidenceClass III evidence
(retrospective)(retrospective)

8. Integration of Brain-specific TreatmentsIntegration of Brain-specific Treatments
into the Initial Resuscitationinto the Initial Resuscitation
 OptionsOptions::
 When signs of transtentorial herniation or progressiveWhen signs of transtentorial herniation or progressive
neurologic deterioration not attributable toneurologic deterioration not attributable to
extracranial explanations are present, it should beextracranial explanations are present, it should be
assumed that intracranial hypertension is present andassumed that intracranial hypertension is present and
it should be treated aggressively; includingit should be treated aggressively; including
hyperventilation, mannitol and adequate volumehyperventilation, mannitol and adequate volume
resuscitation. Sedation & neuromuscular blockaderesuscitation. Sedation & neuromuscular blockade
can be useful when transportation.can be useful when transportation.

9. Resuscitation of Blood PressureResuscitation of Blood Pressure
and Oxygenationand Oxygenation
 GuidelinesGuidelines::
 HypotensionHypotension (SBP<90mmHg) or(SBP<90mmHg) or hypoxiahypoxia (apnea,(apnea,
cyanosis or PO2<60mmHg) should becyanosis or PO2<60mmHg) should be avoidedavoided..
 OptionsOptions::
 MAPMAP should beshould be maintained >90mmHgmaintained >90mmHg throughoutthroughout
treatment totreatment to maintainmaintain CPP >70mmHgCPP >70mmHg

10. Intracranial Pressure (ICP) MonitoringIntracranial Pressure (ICP) Monitoring
IndicationsIndications
 GuidelinesGuidelines::
 1.1. Severe head injurySevere head injury withwith abnormal CT-scanabnormal CT-scan onon
admission.admission.
 Severe head injury is defined asSevere head injury is defined as GCS of 3-8 after CPRGCS of 3-8 after CPR..
 Abnormal CT means with hematoma, contusion, edema,Abnormal CT means with hematoma, contusion, edema,
compressed cisterns.compressed cisterns.
 2.2. Severe head injurySevere head injury withwith normal CTnormal CT if two or more of theif two or more of the
following featuresfollowing features
 are noted at admission: age>are noted at admission: age> 40 yrs40 yrs, uni/bilateral, uni/bilateral posturingposturing,,
SBP<90mmHgSBP<90mmHg..
 3.3. Not routinely indicatedNot routinely indicated in mild or moderate head injury.in mild or moderate head injury.

11. ICP Treatment ThresholdICP Treatment Threshold
GuidelinesGuidelines::
ICP treatmentICP treatment should be initiated at uppershould be initiated at upper
threshold ofthreshold of 20-25mmHg20-25mmHg..

12. Recommendation for ICP MonitorRecommendation for ICP Monitor
 Ventricular catheterVentricular catheter connected to an externalconnected to an external
drainage (EVD)is thedrainage (EVD)is the mostmost
 accurateaccurate, low cost and reliable, low cost and reliable
 Other methods:Other methods:
 Parenchymal ICP monitor (fiberoptic)Parenchymal ICP monitor (fiberoptic)
 Subarachnoid, subdural, epidural monitors: less accurateSubarachnoid, subdural, epidural monitors: less accurate

13. HyperventilationHyperventilationStandardsStandards
ChronicChronic prolonged hyperventilationprolonged hyperventilation therapy (PCO2<25therapy (PCO2<25
mmHg) should bemmHg) should be avoidedavoided in absence ofin absence of ↑↑ICPICP
GuidelinesGuidelines
Use ofUse of prophylactic hyperventilationprophylactic hyperventilation (PCO2<35 mmHg)(PCO2<35 mmHg)
should beshould be avoidedavoided..
OptionsOptions::
Hyperventilation therapy may be necessary forHyperventilation therapy may be necessary for brief periodsbrief periods
when there iswhen there is acute neurologic deteriorationacute neurologic deterioration, or for, or for longerlonger
periodsperiods if there isif there is intracranial hypertension refractoryintracranial hypertension refractory toto
sedation, paralysis, CSF drainage and osmotic diuretics.sedation, paralysis, CSF drainage and osmotic diuretics.
Jugular venous oxygen saturation (SjO2), arterial-jugularJugular venous oxygen saturation (SjO2), arterial-jugular
venous oxygen content differences (AVdO2) and CBFvenous oxygen content differences (AVdO2) and CBF
monitoring maybe helpful when PCO2<30mmHg.monitoring maybe helpful when PCO2<30mmHg.

14. Cerebral Perfusion Pressure (CPP)Cerebral Perfusion Pressure (CPP)
 OptionsOptions
CPPCPP should beshould be maintained at minimum of 70maintained at minimum of 70 mmHgmmHg..
 Critical parameter for brain function & survivalCritical parameter for brain function & survival
 CBF depends on CPPCBF depends on CPP
 CPP = MAP – ICPCPP = MAP – ICP
 In TBI, recommended CPPIn TBI, recommended CPP ≥≥ 70 mmHg70 mmHg

15. Use of SteroidsUse of Steroids
 StandardsStandards
NNot recommendedot recommended for improving outcome orfor improving outcome or ↓↓ ICP.ICP.
No known beneficial role.No known beneficial role.

16. Use of MannitolUse of Mannitol
Hyperosmolar TherapyHyperosmolar Therapy
 GuidelinesGuidelines
 Effective for control of raised ICPEffective for control of raised ICP after severe HI.after severe HI.
 Intermittent bolusesIntermittent boluses more effective than continuous infusion.more effective than continuous infusion.
 Effective doses:Effective doses: 0.25g ~ 1 ~1.5 g/Kg0.25g ~ 1 ~1.5 g/Kg..
 OptionsOptions
 Indications for its use prior to ICP monitoring are signs ofIndications for its use prior to ICP monitoring are signs of
transtentorial herniation or progressive neurological deterioration nottranstentorial herniation or progressive neurological deterioration not
attributable to systemic pathology.attributable to systemic pathology.
 Serum osmolalitySerum osmolality should be keptshould be kept below 320 mOsmbelow 320 mOsm..
 EuvolemiaEuvolemia should be maintained by fluid replacement.should be maintained by fluid replacement.
 Foley catheter should be inserted.Foley catheter should be inserted.

17. Use of BarbituratesUse of Barbiturates
 GuidelinesGuidelines
High-dose barbiturate maybe considered inHigh-dose barbiturate maybe considered in hemodynamicallyhemodynamically
stablestable salvageable severe head injury patients withsalvageable severe head injury patients with
intracranial hypertension refractoryintracranial hypertension refractory to maximal medicalto maximal medical
and surgical ICP lowering therapy.and surgical ICP lowering therapy.
 Barbiturate ComaBarbiturate Coma
IndicationsIndications: otherwise intractable intracranial hypertension: otherwise intractable intracranial hypertension
BarbituratesBarbiturates functionsfunctions:: ↓↓ ICP byICP by ↓↓ cerebral metabolismcerebral metabolism
O2 use & blood flowO2 use & blood flow

18. Nutritional SupportNutritional Support
 GuidelinesGuidelines
ReplaceReplace
 140% of BMR140% of BMR inin non-paralyzednon-paralyzed patientspatients
 100% of BMR100% of BMR inin paralyzedparalyzed patients(15% of cal aspatients(15% of cal as
protein)protein)
 OptionsOptions
 Use of feeding viaUse of feeding via gastrojejunostomygastrojejunostomy is preferable.is preferable.

19. Prophylactic Use of Anti-Epileptic DrugsProphylactic Use of Anti-Epileptic Drugs
 StandardsStandards
Prophylactic useProphylactic use of AED isof AED is not recommendenot recommended ford for
prevention of late posttraumatic seizures (PTS).prevention of late posttraumatic seizures (PTS).
It isIt is recommendedrecommended as optional treatment toas optional treatment to prevent earlyprevent early
PTSPTS in patients at high risk for seizures following head injury.in patients at high risk for seizures following head injury.
 IIndicationsndications
All pts with clinically severe head injury and thoseAll pts with clinically severe head injury and those
predisposed to early epilepsy with Phenytoin for at lest 7 days.predisposed to early epilepsy with Phenytoin for at lest 7 days.
 DosagesDosages
Phenytoin: 15 ~ 18 mg/Kg (loading)Phenytoin: 15 ~ 18 mg/Kg (loading)→→ 5 mg/Kg/day5 mg/Kg/day

20. Management of InfectionsManagement of Infections
 No antibiotic for basilar skull fxNo antibiotic for basilar skull fx ±± CSF leakCSF leak
 Perioperative prophylactic IV antibiotic;Perioperative prophylactic IV antibiotic;
 single dose I hr prior to cranial surgery & 2 dosessingle dose I hr prior to cranial surgery & 2 doses
postoperative.postoperative.
 If drain is present continue until drain is removed.If drain is present continue until drain is removed.

21. Metabolic CareMetabolic Care
 SIADHSIADH
Fluid RestrictionFluid Restriction 1L/day1L/day
High Salt diet/ 3% NaClHigh Salt diet/ 3% NaCl
 HyperglycemiaHyperglycemia
BS> 200mg/dl treated with InsulinBS> 200mg/dl treated with Insulin

22. Summary of Head InjurySummary of Head Injury
ManagementManagement
Avoid Hypotension & HypoxiaAvoid Hypotension & Hypoxia
Maintain MAP > 90 mmHgMaintain MAP > 90 mmHg
Maintain CPP .> 70 mmHgMaintain CPP .> 70 mmHg
ICP Monitoring: IVC (best)ICP Monitoring: IVC (best)
No benefit with use of steroidsNo benefit with use of steroids
Avoid prophylactic use of Anti-convulsivesAvoid prophylactic use of Anti-convulsives
Avoid prolong/prophylac hyperventilationAvoid prolong/prophylac hyperventilation
Mannitol: effective in control of IC-HTNMannitol: effective in control of IC-HTN
Intermittent bolusIntermittent bolus EuvolemicEuvolemic
Avoid hyperosmolalityAvoid hyperosmolality

23. Protocol for Management IC-HTN in HeadProtocol for Management IC-HTN in Head
Injury at TUTHInjury at TUTH
General MeasuresGeneral Measures
 Elevate HOBElevate HOB ≈≈ 3030°°
 Midline head positionMidline head position
 Avoid hypotensionAvoid hypotension Use pressors if reqdUse pressors if reqd
 Maintain euvolemiaMaintain euvolemia
 Control severe HTNControl severe HTN
 Mild sedationMild sedation
 NormoventilationNormoventilation
 Avoid prophylactic HyperventilationAvoid prophylactic Hyperventilation
 Intubation if GCS < 8 or with resp distressIntubation if GCS < 8 or with resp distress

24. Protocol (cont’d)Protocol (cont’d)
First Line TherapyFirst Line Therapy
Heavy sedationHeavy sedation
MannitolMannitol
Mild HyperventilationMild Hyperventilation
CSF DrainageCSF Drainage
Second Line TherapySecond Line Therapy
HypothermiaHypothermia
Moderate HyperventilationModerate Hyperventilation
High-dose BarbiturateHigh-dose Barbiturate
Decompressive craniectomyDecompressive craniectomy

25. Management of Increased ICPManagement of Increased ICP
 Controlled hyperventilationControlled hyperventilation
 Mannitol 0.25 – 0.5g/Kg IV bolusesMannitol 0.25 – 0.5g/Kg IV boluses
 Furosemide (Lasix)Furosemide (Lasix)
 Elevation of CPPElevation of CPP
 Head of bed elevated @ 30Head of bed elevated @ 30°°
 Sedation for restlessnessSedation for restlessness
 Paralytics for severe agitationParalytics for severe agitation
 BarbituratesBarbiturates

26. Level of consciousnessLevel of consciousness
 I Alert (aware os surrounding)I Alert (aware os surrounding)
 II Awake (well-oriented but not aware ofII Awake (well-oriented but not aware of
surrounding)surrounding)
 III Lethargic (can converse, drowsy)III Lethargic (can converse, drowsy)
 IV Stuporous (drowsy, can’t converse, onlyIV Stuporous (drowsy, can’t converse, only
moans and groans, echolalia)moans and groans, echolalia)
 V Semi-comatose (if painful simulus given,V Semi-comatose (if painful simulus given,
will respond)will respond)
 VI ComatoseVI Comatose

27. Coma: three stagesComa: three stages
 Decorticate: no cortical activityDecorticate: no cortical activity
internally rotated flexed hands legs in responseinternally rotated flexed hands legs in response
to painful stimulusto painful stimulus
 Decerebrate: hand extended, internally rotated,Decerebrate: hand extended, internally rotated,
and leg extended in response to painand leg extended in response to pain
 Non-responsive: No response to painNon-responsive: No response to pain

28. Linear Skull Fracture
(Pingpong)
Preope CT

29. Linear (Stellate) Skull Fracture

30. Compound Depressed Skull Fracture

31. Epidural Hematoma
Frontal
Posterior Fos

32. Preope Postope
Epidural Hematoma

33. Gun Shot Wound
PostoperativePostoperative Preope CT
Skull X-ray
Preope CT
(Bone Window)
Preperative
Postoperative

34. Gund Shot Wound
Intraoperative View
Bullet Bone Fragments
Before Cranioplasty After Cranioplasty
Pericranial flap

35. Penetrating Brain Injury
(Sharp Glass)

36. Cerebral Contusion
Preope CT Postope CT

37. Scalp Laceration
Skull Fracture
Tension

38. Cerebellar Contusion
Transverse Sinus Laceration
Preope CT