HEAD TRAUMA

dr. Nasir Lamhot, Sp. BS

Meningeal Layers
Physiology: ICP
Intracranial Pressure increased ICP
decreased cerebral bloodflow + ischemia
Normal ICP = 20mmHg
Physiology: Monro-Kellie Doctrine
Total intracranial volume has to be constant.
increased ICP venous blood + CSF pumped
out compensation mechanism
Physiology: Cerebral Blood Flow
Cerebral Perfusion Pressure = Mean Arterial
Pressure Intracranial Pressure
TBI decreased MAP, increased ICP
decreased CPP
Classification
Severity
Minor GCS 13-15
Moderate GCS 9-12
Severe GCS 3-8
Classification
Morphology
Skull fracture
Vault
Linear vs Stelata
Depressed / nondepressed
Open/closed
Basillar
With/without CSF leak
With/without seventh nerve palsy
Intracranial lession
Focal (EDH, SDH, ICH)
Diffuse (Concussion, multiple contusions,
hypoxic/ischemic injury, axonal injury)
Skull Fractures
Basilar skull fracture:
Racoon eyes (periorbital ecchymosis)
Battles sign (retroauricular ecchymosis)
Rhinorrhea (CSF leakage)
Otorrhea (CSF leakage)
7th and 8th nerve dysfucntion (facial paralysis and
hearing loss)
Intracranial Lessions : Diffuse
Severe diffuse injuries often result from a
hypoxic, ischemic insult to the brain due to
prolonged shock or apnea occuring immediately
after the trauma.
High velocity impact / deceleration injury
punctate hemorrhage often seen in the border
between grey matter and hite matter DAI
(Diffuse Axonal Injury)
Intracranial Lessions : Focal
EDH (epidural hematoma)

SDH (subdural hematoma)

ICH (intracranial hematoma)

 EDH
Uncommon occuring
only 0,5%
Hematoma biconvex /
lenticular
@ temporal /
temporoparietal region
middle meningeal artery
Lucid interval classic
presenteation of EDH
SDH
Common >> EDH
occuring 30% in brain
injuries
Bleeding source
bridging vein
Shape conform the
contours of the brain
More severe >> EDH
parenchymal injury
Contusions and ICH
Cerebral contusion fairly common 20-30%
in brain injuries
@frontal, temporal lobes
Hours, days evolve intracerebral
hematoma mass effect requiring surgical
evacuation
Management: Minor Brain Injury
Management: Moderate Brain Injury
Management: Severe Brain Injury
Indication for CT Scanning MTBI
High risk:
GCs <15 2 hours after injury
Suspect : open / depressed fracture
Sign of basillar skull fracture
Vomiting (>2 episodes)
Age >65 years old
Indication for CT Scanning MTBI
Moderate risk:
Loss of consciusness > 5 minutes
Amnesia before impact > 30 minutes
Dangerous mechanism
Primary Survey
Step 1 : ABCDE
Step 2: Immobilize and stabilize the cervical
spine
Step 3: Brief neurologic examination
pupillary response, GCS, lateralizing signs
Secondary Survey
Step 1: Inspect : head, face
laceration, CSF leakage from nose/ear
Step 2: Palpate : head, face
fracture, laceration overlying fracture
Step 3: Inspect : all scalp laceration
brain tissue, depressed skull fracture, debris CSF
leaks
Step 4: determine GCS + pupillary response
eye-opening response, best limb motor response
Medical Therapies: IVFD
Intravenous fluid prevent hypovolemia
HARMFUL
Recommendation ringer lactate / normal
saline
Medical Therapies: Mannitol
Reduce elevated CP
Important!! Do not give mannitol to hypotensive
patient! osmotic diuretic more hypotensive
Indication : acute neurologic deterioration
dilated pupils, hemiparesis, loss of
consciousness
1g/kg; bolus in 5 minutes
Medical Therapies : Hypertonic Saline
Preferable in hypotensive patient do not act
as diuretic
Surgical Treatment
Scalp wound
Depressed skull fracture
Intracranial mass lesions
Penetrating brain injuries
Source
ATLS 9th edition