Introduction Anatomy Scalp Skull Meninges Brain Ventricular System Intracranial Compartments Physiology Review Intracranial Pressure (ICP) Cerebral Blood Flow (CBF) Classification of head injuries Mild Brain Injury (GCS Score 13–15) Moderate Brain Injury (GCS Score 9–12) Severe Brain Injury (GCS Score 3–8) Morphology Skull Fractures Intracranial Lesions Management: Treatments, Monitoring, Thresholds Decompressive Craniectomy (DC) Prophylactic Hypothermia Hyperosmolar Therapy Cerebrospinal Fluid Drainage Ventilation Therapies Anesthetics, Analgesics, and Sedatives Deep Vein Thrombosis Prophylaxis Seizure Prophylaxis Infection Prophylaxis Intracranial Pressure Monitoring Cerebral Perfusion Pressure Monitoring Advanced Cerebral Monitoring Transcranial Doppler (TCD)/duplex sonography Differences between arterial and arterio-jugular venous oxygen (AVDO2) Measurements of local tissue oxygen

1. Head Trauma
Done by: Dr. Faisal Rawagah
Supervised by: Dr. Tareq Kanaan
Jordan University Hospital 11.08.2022

2. Outline
● Introduction
● Anatomy
● Physiology Review
● Classification of head injuries
● Management: Treatments, Monitoring, Thresholds
● References

3. Introduction

4. Traumatic Brain Injuries TBI Data (in United States)
• Most common types of trauma encountered in emergency departments.
• 90% of prehospital trauma-related deaths involve brain injury.
• 1,700,000 traumatic brain injuries (TBIs) occur annually.
• Approximately 223,135 TBI-related hospitalizations in 2019 and 64,362 TBI-related deaths in 2020.
• 80,000 to 90,000 people experience long-term disability.
-CDC; Traumatic Brain Injury-related Deaths by Age Group, Sex, and Mechanism of Injury.
-CDC; National Center for Health Statistics: Mortality Data on CDC WONDER. Accessed 2022.
-Advanced Trauma Life Support Student Course Manual 10th edition

5. Anatomy

6. Scalp
● Scalp lacerations can result in major blood loss, hemorrhagic shock, and even death.

7. Skull
● The anterior fossa
○ Houses the frontal lobes.
● The middle fossa
○ Houses the temporal lobes.
● The posterior fossa
○ Contains the lower brainstem and
cerebellum.

8. Meninges
● Internal surface of the skull
-Meningeal Arteries
(middle meningeal artery)
● Dura mater
○ Periosteal Layer
-Midline Superior Sagittal
Sinus drains into the
bilateral Transverse and
Sigmoid Sinuses
○ Meningeal Layer
-Bridging Veins
● Arachnoid mater
-Cerebrospinal fluid (CSF)
● Pia mater

9. Brain
● Cerebrum
o The frontal lobe
o The parietal lobe
o The temporal lobe
o The occipital lobe
● Brainstem
○ Midbrain
○ Pons
○ Medulla
● Cerebellum

10. Ventricular System
● CSF is constantly
produced within the
ventricles and absorbed
over the surface of the
brain.

11. Intracranial Compartments
● The tentorium cerebelli divides the
intracranial cavity into the
supratentorial and infratentorial
compartments.

12. Physiology
Review

13. ● Normal ICP- 10 mm Hg.
● Sustained and refractory ICP more
than 22 mm Hg associated with
poor outcomes.
● Monro–Kellie Doctrine
Intracranial Pressure (ICP)

14. ● Traumatic Brain Injury (TBI) that is severe enough to
cause coma can markedly reduce cerebral blood
flow (CBF).
● CPP = MAP – ICP
● CBF = k * CPP * 𝑑4
/ 8 * l * v
● MAP of 50 to 150 mm Hg is “autoregulated” to
maintain a constant CBF.
● Cerebral blood vessels also constrict or dilate in
response to changes in the partial pressure of
oxygen (PaO2) and the partial pressure of carbon
dioxide (PaCO2) in the blood (chemical regulation).
● MAP - mean arterial blood pressure
● CPP - cerebral perfusion pressure
Cerebral Blood Flow (CBF)

15. Classification of
head injuries

16. ● Mild Brain Injury (GCS Score 13–15)
● Moderate Brain Injury (GCS Score 9–12)
● Severe Brain Injury (GCS Score 3–8)
● Canadian CT Head Rule (CCHR) for patients
with minor head injury ->
Severity of Injury
-Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, Wells GA. Performance of the
Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed
tomography in a United States Level I trauma center. Acad Emerg Med. 2012 Jan;19(1):2-10. doi: 10.1111/j.1553-
2712.2011.01247.x. PMID: 22251188; PMCID: PMC5637409.
-Adapted from Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients
with minor head injury. Lancet 2001; 357:1294.

17. ● Skull Fractures
○ Cranial vault or Skull base
○ Linear or Stellate
○ Open or Closed
● Intracranial Lesions
○ Diffuse Brain Injuries
• Range from mild concussions
• Diffuse edema
• Diffuse axonal injury
• to severe hypoxic, ischemic injuries
○ Focal Brain Injuries
• Epidural Hematomas
• Subdural Hematomas
• Subarachnoid hemorrhage
• Contusions and Intracerebral Hematomas
Morphology

18. Skull Fractures

19. Intracranial Lesions

20. GCS Score 3–8
Intubation and ventilation for airway protection
CT scan in all cases
GCS Score 13–15
Canadian CT Head Rule (CCHR)
Management
Mild Brain Injury
GCS Score 9–12
CT scan in all cases
Transfer to definitive Neurosurgical
evaluation and management
Severe Brain Injury
Moderate Brain Injury

21. ● Decompressive Craniectomy (DC) - as a secondary procedure after ICP targeted medical
therapies have failed.
● Prophylactic Hypothermia - Early (within 2.5 hours), short-term (48 hours post-injury)
prophylactic hypothermia is not recommended to improve outcomes. (Level II B)
● Hyperosmolar Therapy –
○ Hypertonic saline administration may be hazardous for a hyponatremic patient.
○ Mannitol - doses of 0.25 g/kg to 1 g/kg body weight, avoid if systolic blood
pressure <90 mm Hg.
○ Restrict mannitol use prior to ICP monitoring.
I: Treatments

22. ● Cerebrospinal Fluid Drainage -
○ EVD continuous drainage of CSF more effectively than intermittent use. (Level III)
○ CSF drainage to lower ICP in patients with an initial Glasgow Coma Scale (GCS) <6
during the first 12 hours after injury may be considered. (Level III)
● Ventilation Therapies –
○ Prolonged prophylactic hyperventilation with (PaCO2) of 25 mm Hg or less is not
recommended. (Level II B)
○ Hyperventilation is recommended as a temporizing measure. (Level III)
○ Should be avoided during the first 24 hours after injury . (Level III)
○ If used, jugular venous oxygen saturation (SjO2) or brain tissue O2 partial pressure
(BtpO2) measurements are recommended. (Level III)
I: Treatments

23. ● Anesthetics, Analgesics, and Sedatives –
○ Barbiturates to induce burst suppression measured by EEG as prophylaxis against
the development of intracranial hypertension is not recommended. (Level II B)
○ High-dose barbiturate administration is recommended to control elevated ICP
refractory to maximum standard medical and surgical treatment. Hemodynamic
stability is essential before and during barbiturate therapy. (Level II B)
○ Propofol is recommended for the control of ICP, it is not recommended for
improvement in mortality or 6-month outcomes. Caution is required as high-dose
propofol can produce significant morbidity. (Level II B)
● Steroids - is not recommended for improving outcome or reducing ICP, high-dose
methylprednisolone was associated with increased mortality and is contraindicated.
(Level I) (CRASH trial).
I: Treatments

24. ● Nutrition -
○ At least by the fifth day and, at most, by the seventh day post-injury. (Level II A)
○ Transgastric jejunal feeding is recommended. (Level II B)
● Infection Prophylaxis -
○ Early tracheostomy is recommended. (Level II A)
○ The use of povidone-iodine (PI) oral care is not recommended. (Level II A)
○ Antimicrobial-impregnated catheters (+EVD) may be considered. (Level III)
● Deep Vein Thrombosis Prophylaxis - Low molecular weight heparin (LMWH) or low-dose
unfractioned heparin may be used in combination with mechanical prophylaxis. However,
there is an increased risk for expansion of intracranial hemorrhage. (Level III)
● Seizure Prophylaxis –
○ Prophylactic use of phenytoin or valproate is not recommended for preventing late
post-traumatic seizures (PTS)
○ Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of
injury)
I: Treatments

25. ● Intracranial Pressure Monitoring -
○ Management of severe TBI patients using
information from ICP monitoring is
recommended to reduce in-hospital and 2-
week post-injury mortality.
○ All salvageable patients with a severe
traumatic brain injury (TBI) and an abnormal
computed tomography (CT) scan .
○ If normal CT scan two or more of the following
ICP monitoring is indicated (age over 40 years,
unilateral or bilateral motor posturing, or
systolic BP <90 mm Hg. )
● Cerebral Perfusion Pressure Monitoring - CPP is
defined as the pressure gradient across the cerebral
vascular bed, between blood inflow and outflow.
○ CPP = MAP - ICP
II: Monitoring

26. ● Transcranial Doppler
(TCD)/duplex sonography
● Differences between arterial and
arterio-jugular venous oxygen
(AVDO2)
● Measurements of local tissue
oxygen
○ Near-infrared spectroscopy
(NIRS) Based Monitoring
○ Microdialysis
Advanced Cerebral Monitoring
Zhong,W.; Ji, Z.; Sun, C. A Review of Monitoring Methods for Cerebral Blood Oxygen Saturation. Healthcare 2021, 9, 1104. https://doi.org/10.3390/healthcare9091104

27. ● Blood Pressure
○ Maintaining SBP at ≥100 mm Hg for patients 50 to 69 years old or at ≥110 mm Hg
or above for patients 15 to 49 or over 70 years old.
● Intracranial Pressure (Normal 0-10 mm Hg)
○ Treat ICP above 22 mm Hg
● Cerebral Perfusion Pressure
○ between 60 and 70 mm Hg.
○ Avoiding aggressive attempts to maintain CPP above 70 mm Hg.
● Advanced Cerebral Monitoring
○ Jugular venous saturation of <50% may be a threshold to avoid.
III: Thresholds

28. $3
Our References
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PREMIUM
• CDC; Traumatic Brain Injury-related Deaths by Age Group, Sex, and Mechanism of Injury.
• CDC; National Center for Health Statistics: Mortality Data on CDC WONDER. Accessed 2022.
• Advanced Trauma Life Support Student Course Manual 10th edition
• Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, Wells GA. Performance of the
Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on
computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012 Jan;19(1):2-10. doi:
10.1111/j.1553-2712.2011.01247.x. PMID: 22251188; PMCID: PMC5637409.
• Adapted from Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor
head injury. Lancet 2001; 357:1294.
• https://www.uptodate.com/contents/image?imageKey=RADIOL%2F83506
• Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA,
Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for
the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi:
10.1227/NEU.0000000000001432. PMID: 27654000.
• Zhong,W.; Ji, Z.; Sun, C. A Review of Monitoring Methods for Cerebral Blood Oxygen Saturation. Healthcare
2021, 9, 1104. https://doi.org/10.3390/healthcare9091104

29. Supervised by:
Dr. Tareq Kanaan
Neurosurgery Consultant
Done by:
Dr. Faisal Rawagah
Intensivist and General Surgeon
Jordan University Hospital 11.08.2022
THANKS!