2. Introduction
■ Definition: Head injury is Alteration in mental or physical
functioning related to trauma
■ Central nervous system injuries remain the leading cause of
morbidity and mortality for young people throughout the
world.
■ The risk of incurring a traumatic brain injury (TBI) is
especially high among adolescents, young adults, and elderly
people.
– For example, the management of depressed skull fractures in
children at Muhimbili Medical Centre, Dar es Salaam, Tanzania is
described by Mlay and Sayi.
– The fractures were located in the frontal or parietal bone in 27
(76.3%) patients.
– Casualty officers should note the indications for surgery were
cosmetics in 15 patients, compound fracture in 3 patients, focal
neurological deficit in 2 patients, and torn dura presenting with
Pseudo-meningocele in 2 patients.
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6. Anatomy: Meninges
■ The meninges of the brain and potential sites for
hemorrhage
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Brain
Calvarium
Dura Mater
Arachnoid
Pia Mater
Potential Space
CSF
Potential Space
Epidural Hematoma (meningeal arteries)
Subdural Hematoma (bridging veins)
Subarachnoid Hemorrhage into CSF
7. Physiology
■ Cerebral Blood Flow (CBF):
– Normal CBF = 50 ml/100 gm of tissue
– Loss of cell function occurs at < 20-25
– Cell death of irreversible damage occurs at < 5
■ Autoregulation:
– the brain can maintain a constant CBF with a CCP
(Cerebral Perfusion Pressure) of 50-150 mm Hg
through vasoconstriction and vasodilatation
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8. Physiology
■ Cerebral Perfusion Pressure (CPP): CPP = MAP – ICP
■ Intracranial Pressure (ICP):
■ Normal 5-15 mm Hg
■ Abnormal > 20
■ Severe > 40
■ CCP must be maintained > 70 mm Hg
■ The autoregulatory function is often lost in TBI patients
■ MAP and ICP must be carefully monitored in TBI patients
■ Low CPP must be treated aggressively to maintain CBF
– Increase MAP
– Decrease ICP
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10. Classification of TBI - Morphology
■ Scalp Lacerations
– Can result in major blood loss
– Treatment
■ Direct pressure
■ Ligation of the bleeding vessels
■ Injection of lidocaine with epinephrine into the bleeding
areas
■ Multi-layer closure of the wound (always close torn
galea)
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11. Skull Fractures
■ Cranial vault fractures
■ Linear or stellate
■ Open or closed
■ Depressed or non-depressed
– Fragments depressed greater than skull
thickness require elevation
■ Basilar skull fractures (BSF)
■ Periorbital ecchymosis (raccoon eyes)
■ Retroauricular ecchymosis (Battle’s sign)
■ CSF leaks (rhinorrhea, otorrhea)
■ Hemotympanum (blood behind the eardrum)
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12. Basilar Skull Fractures (BSF)
■ DO NOT place NGT’s in
patients with suspected or
known BSF!!!
■ This patient clearly has
physical signs of a BSF, yet
inappropriately had an NGT
placed!!!!!
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13. Basilar Skull Fractures (BSF)
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What is the PROBLEM in this picture?
15. Cerebral Contusion
■ Common injury
■ Often seen in association with
SDH and SAH
■ Most common in frontal and
temporal lobes, occasionally in
occipital lobes
■ “Coup” or “contrecoup” injuries
■ Tissue disruption leads to
increased vascular
permeability and edema
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16. Epidural Hematoma
■ Relatively uncommon
■ More common in young & active
■ Between the dura and skull
■ Biconvex in shape
■ Result of tearing of meningeal
arteries
■ Often associated with skull
fracture
■ Usually minimal damage to brain
parenchyma
■ Prognosis good if evacuated
quickly
■ Classic History: Lucid interval
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17. Subdural Hematoma
■ More common injury (30%)
■ More common in older & alcoholics
■ Under the dura
■ Crescent shaped
■ Covers surface of hemisphere
■ Result of tearing bridging veins
■ Associated with blunt trauma to
underlying parenchyma
■ Prognosis worse due to more diffuse
injury
■ Requires prompt evacuation
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SDH with MLS
18. Subarachnoid Hemorrhage
■ Most common finding in moderate to
severe TBI (40%)
■ Blood noted in cisterns and sulci
■ Results from tear in subarachnoid
vessels
■ May precipitate vasospasm
■ Often associated with meningeal
signs:
– Photophobia
– Neck stiffness
– Headache
■ Requires neurosurgical consultation
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19. Diffuse Axonal Injury
■ Occur with rapid acceleration and
deceleration injuries
■ Causes disruption of axonal fibers
by shear forces in white matter and
BS
■ Effects are rapid and irreversible
■ Associated with edema and
increased ICP
■ Non-specific pattern on CT with loss
of G-W interface and diffuse swelling
■ “Shaken-baby syndrome”
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20. Glasgow Coma Scale (GCS)
■ Main Components
– Eyes
– Verbal
– Motor
■ Scoring
– Mild Injury 14-15
– Moderate Injury 9-13
– Severe Injury 3-8
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21. Glasgow Coma Scale (GCS)
■ Eyes
– 1 – Closed
– 2 - Opens to pain
– 3 - Opens to voice
– 4 - Open
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22. Glasgow Coma Scale (GCS)
■ Verbal
– 1 – Silent
– 2 – Moans
– 3 - Inappropriate words
– 4 - Disoriented or confused
– 5 - Oriented and appropriate
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23. Glasgow Coma Scale (GCS)
■ Motor
– 1 - No response
– 2 - Extension to pain
– 3 - Flexion to pain
– 4 - Withdraws from pain
– 5 - Localizing pain
– 6 - Follows commands
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24. Evaluation
■ Critical Components of History:
■ Age
■ Sex
■ Mechanism of injury
■ Time of injury
■ Loss of consciousness
■ Level of alertness
■ Amnesia
■ Headache
■ Seizures
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27. Evaluation of TBI
■ CT scan is the imaging modality of choice
– Indications for CT scan in trauma patient:
■ Loss of consciousness
■ Amnesia
■ Neurological signs or symptoms
■ Decreased level of consciousness (GCS < 14)
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28. Evaluation of TBI
■ CT scan is the imaging modality of choice
– Indications for CT scan in trauma patient:
■ Seizure activity
■ Mental status difficult to evaluate: drugs, alcohol, anesthesia
■ Prior to surgery if surgery is required for other injuries
■ (Headache without these other signs is no longer included)
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29. Management - General Principles
■ Address ABC’s first
■ If ABC’s are intact and patient has a
depressed level of consciousness, ASSUME
head injury
■ If patient has a head injury, ASSUME C-spine
injury
■ In patient with significantly depressed level of
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30. Treatment
■ East African practitioners will often:
– Perform hourly neurological observations which
should be recorded clearly and include:
■ Glasgow coma score
■ Blood pressure, pulse and respiratory rate
■ Pupil size and reaction
■ Limb movements (normal, mild weakness, severe
weakness, spastic flexion, extension, no response)
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31. Treatment to Control ICP
■ Intravenous fluids
■ Mannitol
■ Anesthesia and sedation
■ Anticonvulsants
■ ICP monitoring
■ Raise the head of the bed 30 degrees for increased ICP
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32. Ventilation
■ Prevent Hypoxia
– Maintain PO2 > 60 mm Hg
■ Maintain Low Normal PCO2
– PCO2 = 30-35 mm Hg
– Hyperventilation with
hypocapnea causes
constriction of cerebral
vessels, possibly leading to a
reduction in CBF
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33. Intravenous Fluids
■ Volume Status:
– Maintain the patient NORMOVOLEMIC
■ Use venous or Swan-Gantz catheter to monitor volume
status
■ Fluid Types:
– Isotonic only
■ NS or LR
– No glucose containing solutions
■ Glucose is broken down into lactic acid in the damaged
tissue and further increases brain injury
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34. Mannitol
■ Mechanisms
■ Immediate:
– Expands circulating volume and decreases viscosity
– Increases CBF and O2 delivery
■ Delayed (15-30 min):
– Osmotic diuretic
– Assists in drawing free water from CNS across BBB
■ Dose:
■ 0.5-1 gm/kg
■ Given as one time bolus
■ Do NOT use for long term
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35. Sedation and Anesthesia
■ Keep patient sedated and anesthetized
■ Reduces muscles tone and contractions to minimize ICP
elevation
■ Barbituate Coma
■ Indications:
– Increase ICP with no surgical lesion
– Other methods have failed to control ICP
– Low GCS
■ Benefits:
– Decreases cerebral metabolic rate
– Decreases cerebral blood volume and ICP
– Promotes hypothermia
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36. Anticonvulsants
■ Seizure can increase tissue damage by:
■ Increasing hypoxia
■ Increasing ischemia
■ Increasing ICP
■ Risk factors:
■ Intracranial hemorrhage
■ Depressed skull fracture
■ Recommendations for severe TBI:
■ Anticonvulsant prophylaxis for 1 week post event
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37. ICP Monitoring
■ Intraventricular Catheter (IVC):
■ Invasive measure of ICP
■ Most accurate and reliable method to
monitor ICP
■ Can be used for continuous monitoring
■ Catheter placed through burr hole in
calvarium and through parenchyma into
lateral ventricle
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38. Burr Hole
■ Criteria for
explorative burr hole
– No CT scan
– No neurosurgical
services
– Rapid deterioration
– Herniation
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41. Summary
■ Address the ABC’s First
■ Primary Goals:
■ Identify life-threatening injuries and treat immediately
■ Prevent secondary brain injury by avoiding hypoxia
and hypotension
■ Identify decompressible mass lesions early by CT
■ Intubate early
■ Treat hypotension aggressively
■ Frequently reassess the patient’s neuro status and
vitals
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