Head TraumaHead Trauma

Objectives:Objectives:

A- Review specific of anatomy and A- Review specific of anatomy and physiology as related to head physiology as related to head injuries.injuries.

B- Identify the principles of B- Identify the principles of general management of the general management of the unconscious traumatized patient unconscious traumatized patient and the delayed complications.and the delayed complications.

C- Outline the method of C- Outline the method of evaluating head injuries using a evaluating head injuries using a mininurological examination.mininurological examination.

D- Explain the management D- Explain the management techniques to be used in specific techniques to be used in specific types of head injuries.types of head injuries.

E- Demonstrate the ability to assess E- Demonstrate the ability to assess various types of head, maxillofacial various types of head, maxillofacial and neck injuries using a head-and neck injuries using a head-trauma model.trauma model.

F- Explain clinical signs and outline F- Explain clinical signs and outline priorities for initial management of priorities for initial management of injuries identified in the assessment.injuries identified in the assessment.

Head TraumaHead Trauma

• Neurosurgical consult essentialNeurosurgical consult essential• Early transfer reduces morbidity and Early transfer reduces morbidity and

mortalitymortality• CardiorespiratoryCardiorespiratory• Level of consciousnessLevel of consciousness• Pupillary reactionPupillary reaction• Vital signsVital signs• Associated injuriesAssociated injuries• Skull film resultsSkull film results

Cranial Nerve AssessmentCranial Nerve Assessment• Pupils occulomotor nerve Pupils occulomotor nerve

( IIIrd )( IIIrd )• Others- lower assessment Others- lower assessment

prioritypriority

• Alteration of Consciousness is Alteration of Consciousness is The Hallmark of Brain InjuryThe Hallmark of Brain Injury

Unconsciousness InjuryUnconsciousness Injury

• Bilateral cerebral corticesBilateral cerebral cortices• Brain stem RASBrain stem RAS• Increased ICPIncreased ICP• Decreased CBFDecreased CBF

• Increased ICP Results in:Increased ICP Results in:• Decreased perfusionDecreased perfusion• Altered level of consciousnessAltered level of consciousness

HistoryHistory• Determine cause and effectDetermine cause and effect• Pre- and post injury statusPre- and post injury status• Document communicateDocument communicate• ReassessReassess

Vital signsVital signs• Identifies status neurologically and Identifies status neurologically and

systemically.systemically.• Respiratory AssessmentRespiratory Assessment• Assess and correct deficienciesAssess and correct deficiencies• Increased ICP - slower RRIncreased ICP - slower RR• Increased ICP – noisy tachypneaIncreased ICP – noisy tachypnea• Asses for other etiologyAsses for other etiology

Blood PressureBlood Pressure• Increased ICP Increased BP & Increased ICP Increased BP &

widened pulse pressurewidened pulse pressure• Assess for other etiologyAssess for other etiology• Treat shock vigorouslyTreat shock vigorously

PulsePulse• Increased ICP bradycardiaIncreased ICP bradycardia• Tachycardia grave signTachycardia grave sign• Assess for etiologyAssess for etiology

TemperatureTemperature• TemperatureTemperature• Weather extremesWeather extremes• Control hyperthermiaControl hyperthermia

Eye Opening ResponseEye Opening Response• Spontaneous – already open with Spontaneous – already open with

blinking (normal) : four (4) pointsblinking (normal) : four (4) points• To speech – not necessarily to request To speech – not necessarily to request

eye opening : three (3) pointseye opening : three (3) points• To pain – stimulus should not be to To pain – stimulus should not be to

face : two (2) pointsface : two (2) points• None – make note if eyes are swollen None – make note if eyes are swollen

shut : one (1) pointshut : one (1) point

Verbal ResponseVerbal Response• Oriented - knows name, age, etc. : five Oriented - knows name, age, etc. : five

(5) points(5) points• Confused conversation - still answers Confused conversation - still answers

questions: four (4) pointsquestions: four (4) points• Inappropriate words - speech is either Inappropriate words - speech is either

exclamatory or random : three (3) exclamatory or random : three (3) pointspoints

• Incomprehensible sounds - do not Incomprehensible sounds - do not confuse with partial respiratory confuse with partial respiratory obstruction : two (2) pointsobstruction : two (2) points

• None – make note if intubation None – make note if intubation prevents speech: one (1) pointprevents speech: one (1) point

Best Motor ResponseBest Motor Response• Obeys - moves limb to command Obeys - moves limb to command

and pain is not required: six (6) and pain is not required: six (6) pointspoints

• Localizes - changing the location Localizes - changing the location of the pain stimulus causes the of the pain stimulus causes the limb to follow: five (5) pointslimb to follow: five (5) points

• Withdraws - pulls away from Withdraws - pulls away from painful stimulus: four (4) pointspainful stimulus: four (4) points

• Abnormal flexion - three (3) pointsAbnormal flexion - three (3) points• Extensor response - two (2) pointsExtensor response - two (2) points• No movement - one (1) pointNo movement - one (1) point

C-spine AssessmentC-spine Assessment • High index for suspicionHigh index for suspicion• Reflex assessmentReflex assessment• Sensory assessmentSensory assessment• X-raysX-rays

Hints to Cervical Cord Hints to Cervical Cord InjuryInjury

• Flaccid areflexia, especially with flaccid Flaccid areflexia, especially with flaccid rectal sphincterrectal sphincter

• Diaphragmatic breathingDiaphragmatic breathing• Ability to flex forearms but not extend themAbility to flex forearms but not extend them• Facial grimaces in response to pain above Facial grimaces in response to pain above

the clavicle but not belowthe clavicle but not below• Hypotension without other evidence of Hypotension without other evidence of

shock (ie, hypotensive with warm shock (ie, hypotensive with warm extremities)extremities)

• Priapism is an uncommon but Priapism is an uncommon but characteristic signcharacteristic sign

• Brain stem Brain stem responses :Neurosurgeon to responses :Neurosurgeon to perform occulocephalic & perform occulocephalic & occulovestibular cranial nerve occulovestibular cranial nerve test.test.

• Skull X-raysSkull X-rays• Do not delay primary assessment Do not delay primary assessment

& management to obtain skull X-& management to obtain skull X-rays.rays.

Management Reassessment, Management Reassessment, O2 and AirwayO2 and Airway

ConcussionConcussion• No significant brain injury or No significant brain injury or

localizing signslocalizing signs• History : amnesiac of eventHistory : amnesiac of event• Admit : individualizeAdmit : individualize

ContusionContusion• Significant alterations in Significant alterations in

consciousness and localizing signsconsciousness and localizing signs• Countercoup injuryCountercoup injury• Admit and observe 48 hoursAdmit and observe 48 hours

Intracranial HemorrhageIntracranial Hemorrhage• Meningeal or brainMeningeal or brain• CT - precise or diagnoseCT - precise or diagnose• Clinical findings similarClinical findings similar• Acute epiduralAcute epidural• Middle meningeal artery tearMiddle meningeal artery tear• Rapidly fatalRapidly fatal• Hallmark : ipsilateral, dilated fixed Hallmark : ipsilateral, dilated fixed

pupilpupil• Immediate surgeryImmediate surgery• Prognosis : goodPrognosis : good

Acute SubduralAcute Subdural• Venous hemorrhageVenous hemorrhage• life- threatening gradual onsetlife- threatening gradual onset• severe underlying brain injurysevere underlying brain injury• Prognosis : poorPrognosis : poor

SubarachnoidSubarachnoid• Bloody CSF, meningeal irritationBloody CSF, meningeal irritation• Headache, photophobiaHeadache, photophobia• Nuchal rigidity, R/O C-spine injuryNuchal rigidity, R/O C-spine injury• High index of suspicionHigh index of suspicion• AdmitAdmit

Closed Brain HemorrhagesClosed Brain Hemorrhages• Occur at any locationOccur at any location• CT- precise diagnosisCT- precise diagnosis• Neurological deficits- region and Neurological deficits- region and

size of hemorrhagesize of hemorrhage

Increased ICP ComplicationsIncreased ICP Complications• Cerebral edemaCerebral edema• VasospasmVasospasm• Loss of Loss of

autoregulation( Neurosurgical autoregulation( Neurosurgical consult )consult )

Fluid Restriction Prevent Fluid Restriction Prevent OverhydrationOverhydration

DiureticsDiuretics• Neurological consultNeurological consult• Mannitol 50 gms IVMannitol 50 gms IV• Furosemide 40-80 mg IVFurosemide 40-80 mg IV• Urinary catheterUrinary catheter

Deliberate HypocapniaDeliberate Hypocapnia• Maintain PCO2 at 26-28 torrMaintain PCO2 at 26-28 torr• IntubationIntubation• Latrogenic paralysisLatrogenic paralysis• Monitor ABGs ( Neurosurgical consult )Monitor ABGs ( Neurosurgical consult )

ConvulsionsConvulsions• Intracranial hemorrhageIntracranial hemorrhage

TreatmentTreatment• Diazepam 10mg IVDiazepam 10mg IV• Diphenylhydantoin 1 gm IVDiphenylhydantoin 1 gm IV• Phenobarbital or anaesthesiaPhenobarbital or anaesthesia• RestlessnessRestlessness• Identify etiologyIdentify etiology• Correct causeCorrect cause

HyperthermiaHyperthermia• Potential disastrousPotential disastrous• Reversible neurologic findingsReversible neurologic findings• Vigorous interventionVigorous intervention

Scalp WoundsScalp Wounds• Blood lossBlood loss• InspectionInspection• RepairRepair

Surgical ManagementSurgical Management

• Obtain necessary tests earlyObtain necessary tests early• Emergent surgeries for Emergent surgeries for

hematomashematomas• Transfer to neurosurgeonTransfer to neurosurgeon• Avoid delaysAvoid delays

SummarySummaryA- Obtain and maintain an open airwayA- Obtain and maintain an open airwayB- Ventilate to avoid hypercarbiaB- Ventilate to avoid hypercarbiaC- Treat shock, if present and look for C- Treat shock, if present and look for

causecauseD- Except for shock, restrict fluid intake D- Except for shock, restrict fluid intake

to maintenance levelsto maintenance levelsE- Establish baseline parametersE- Establish baseline parametersF- Search for associated injuriesF- Search for associated injuriesG- Obtain X-rays as needed, but only G- Obtain X-rays as needed, but only

after the patient is stableafter the patient is stableH- Consult a neurosurgeon and H- Consult a neurosurgeon and

consider early transferconsider early transfer

• I- Should the patient's condition I- Should the patient's condition show a change for the worse, show a change for the worse, consider other diagnoses and consider other diagnoses and forms of treatment.forms of treatment.

• Consult with a neurosurgeon and Consult with a neurosurgeon and consider transfer.consider transfer.

• J- Reassess continually to J- Reassess continually to identify changes necessitates identify changes necessitates neurosurgical intervention.neurosurgical intervention.