Head trauma

Self Explanatory.

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What is it?
How is it caused?
What do we do in the field?

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Objectives
Anatomy of head and brain
Pathophysiology of traumatic injury
Primary and secondary injury
Describe the mechanisms for the development of
secondary brain injury

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Describe the assessment of the patient with head
injury
Describe the management of a patient with a
head injury
Identify potential problems in the management of
the patient with head injury
Recognize and describe the management of the
cerebral herniation syndrome

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Anatomy of Head and
Brain

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Pathophysiology of
Traumatic Injury
Open
•Skull compromised
and brain exposed
Closed
•Skull not
compromised
and brain not
exposed

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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

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Skull fracture
•Linear not displaced
•Depressed
•Compound
Suspect fracture
•Large contusion or darkened swelling
Management
•Dressing, avoid excess pressure

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Raccoon Eyes

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Battle Signs

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Penetrating
Trauma

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Bullet
fragments

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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

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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 changeschanges have
personality changes

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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

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Diffuse axonal injury
•Diffuse injury
•Generalized edema
No structural lesion
Most common injury from
severe blunt head trauma
•Associated symptoms
Unconscious
No focal deficits

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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

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Forces that cause skull
fracture can also cause brain
injury.

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Primary brain injury
•Immediate damage
due to force
•Coup and contra coup
•Fixed at time of injury
Management
•Directed at prevention

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Intracranial hemorrhage
•Epidural
Between skull and dura
•Subdural
Between dura and
arachnoid
•Intracerebral
Directly into brain tissue

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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

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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

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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

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Secondary brain injury
•Results from hypoxia
or decreased perfusion
•Response to primary injury
•Develops over hours
Management
•Good prehospital care can help prevent

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Response to injury
•Swelling of brain
Vasodilatation with increased blood volume
Increased ICP
•Decreased blood flow to brain
Perfusion decreases
Cerebralischemia (hypoxia)

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Decreased level of
consciousness
is an early indicator of
brain injury or rising ICP.

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Primary and Secondary Surveys
Limit patient agitation, straining
•Contributes to elevated ICP
Airway
•Vomiting very common within first hour

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Nonreactive: brainstem
Reactive: often reversible
Both DilatedBoth dilated

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Anisocoria

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Eye closure
Slow: cranial nerve III
Fluttering: often hysteria

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Unilaterally dilated
Reactive: ICP
increasing
Nonreactive (altered
LOC): increased ICP
Nonreactive (normal
LOC): not from head
injury

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Extremity Posturing
Decorticate
Arms flexed
and legs extended
Decerebrate
Arms extended
and legs extended

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Cushing’s response
As ICP increases, systolic BP increases
As systolic BP increases, pulse rate
decreases

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

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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
•SpO
2>95%

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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

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Cerebral herniation syndrome
•Herniation danger outweighs hypoxia
If signs resolve, stop hyperventilation.

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Is ICP severe enough
to outweigh cerebral ischemia?

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Summary
Knowledge of central nervous system
•Essential for assessment and management

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Key actions
•Rapid assessment, airway management,
prevent hypotension, frequent ongoing
exams

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Serious head injury has spinal injury
until proven otherwise
Altered mental status common

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Questions and Answers
In patients with closed head injuries, a respiratory
pattern called Cheyne-Stokes breathing occurs. This
pattern is best described as:
A. rapid breathing then shallow breathing
B. slow shallow breathing with periods of apnea and
then deep breathing
C. slow and shallow breathing then deep ventilation
then back to slow and shallow breathing followed by a
period of apnea
D. rapid breathing with periods of apnea

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Answer
C.

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The patient you are treating has suffered
a blow to the back of his head. The most
likely area of the brain affected weould be
the:
A. occipital region
B. parietal region
Temporal region
Frontal region

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Answer
A.