Head

Trauma

Basic Trauma Life Support

 Overview

Anatomy of head and brain

Pathophysiology of traumatic injury

Primary and secondary injury

• Mechanisms of secondary brain injury

Assessment, management, potential problems

Management of cerebral herniation syndrome

 Head Trauma

Traumatic brain injury (TBI)

• Major cause of death and disability
• CNS injury in 40% multiple trauma
• Death rate twice of non-CNS injury
• 25% of trauma fatalities
• 50% of motorcycle fatalities

Assume spinal injury with serious injury

• Potential for altered mental status
Head Anatomy
Brain Anatomy
Intracranial volume
• Brain
• CSF
• Blood vessel volume
• Dilatation with high pCO2
• Constriction with low pCO2
– Slight effect on volume
 Brain Physiology
Intracranial pressure (ICP)
• Pressure of brain and contents in skull

Cerebral perfusion pressure (CPP)

• Pressure required to perfuse brain

Mean arterial pressure (MAP)

• Pressure maintained in vascular system
 Brain Physiology
Cerebral perfusion
• CPP = MAP – ICP
• MAP constant + ICP increase = CPP decrease
• MAP decrease + ICP constant = CPP decrease

• Hypotension not tolerated with ICP increase

• MAP decrease + ICP increase = CPP critical
• Systolic pressure 110–120 mmHg minimum needed
to maintain sufficient CPP
 Head Trauma

Open
• Skull compromised
and brain exposed

Closed
• Skull not compromised
and brain not exposed
 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
 Head Injuries

Skull fracture
• Linear nondisplaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Management
• Dressing, avoid excess pressure
 Basilar Skull Fracture

Battle’s sign Raccoon eyes

 Head Injuries

Penetrating trauma

Bullet fragments
Forces that cause skull fracture
can also cause brain injury.
 Brain Injury

Primary brain injury

• Immediate damage
due to force
• Coup and contracoup
• Fixed at time of injury

Management
• Directed at prevention
 Brain Injury

Secondary brain injury

• Results from hypoxia
or decreased perfusion
• Response to primary injury
• Develops over hours

Management
• Good prehospital care can help prevent
 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)
 Early efforts
to maintain brain perfusion
can be life-saving.
 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
 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
 Brain Injuries

Subarachnoid hemorrhage
• Blood in subarachnoid space
• Intravascular fluid “leaks” into brain
• Fluid “leak” causes more edema

• Associated symptoms
• Severe headache
• Coma
• Vomiting
• Cerebral herniation syndrome possible
 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
 Brain Injuries

Anoxic brain injury

• Small cerebral artery spasms due to anoxia
• No-reflow phenomenon
• Cannot restore perfusion of cortex
after 4–6 minutes of anoxia
• Irreversible damage occurs >4–6 minutes

• Hypothermia seems protective

 Brain Injuries

Intracranial hemorrhage
• Epidural
• Between skull and dura

• Subdural
• Between dura and arachnoid

• Intracerebral
• Directly into brain tissue
 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
 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
 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
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.
 Head Trauma Assessment
BTLS Primary and Secondary Surveys

Limit patient agitation, straining

• Contributes to elevated ICP

Airway
• Vomiting very common within first hour
• Endotracheal intubation
• IV lidocaine no longer recommended
• Nasotracheal or RSI
 Pupils
Both dilated
• Nonreactive: brainstem
• Reactive: often reversible
Eyelid closure
• Slow: cranial nerve III
• Fluttering: often hysteria
Anisocoria
Unilaterally dilated
• Reactive: ICP increasing
• Nonreactive (altered LOC):
increased ICP
• Nonreactive (normal LOC): not from
head injury
 Extremity Posturing

Decorticate
• Arms flexed
and legs extended

Decerebrate
• Arms extended
and legs extended
 Glasgow Coma Scale

Suspect severe brain injury GCS <9

*Decorticate posturing to pain

**Decerebrate posturing to pain
 Increasing ICP
Vital Sign Change with Increasing ICP
Respiration Increase, decrease, irregular
Pulse Decrease
Blood pressure Increase, widening pulse pressure

Cushing’s response
• As ICP increases, systolic BP increases
• As systolic BP increases, pulse rate decreases
 The Injured Brain

Hypotension
• Single instance increases mortality
• Adult (systolic <90 mmHg) 150%
• Child (systolic < age appropriate) worse

Fluid administration for TBI GCS <9

• Titrate to 110–120 mmHg systolic
with or without penetrating hemorrhage
to maintain CPP
 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
 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
 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.

 Hyperventilation Rates
Age Group Normal Rate Hyperventilation
Adult 8–10 per minute 20 per minute
Children 15 per minute 25 per minute
Infants 20 per minute 30 per minute

Capnography
• Maintain EtCO2 <30 mmHg, but >25 mmHg
 Cerebral Herniation

Is ICP severe enough

to outweigh cerebral ischemia?
 Summary

Knowledge of central nervous system

• Essential for assessment and management

Key actions
• Rapid assessment, airway management, prevent
hypotension, frequent Ongoing Exams

Serious head injury has spinal injury

until proven otherwise
• Altered mental status common