HEAD INJURY

Andi Asadul Islam

Department of Surgery Faculty of Medicine Hasanuddin University

Head Injury
Common problem High morbidity and mortality Secondary insults
Worsen outcome Often preventable

Early neurosurgical consult and transfer

Neurosurgeon Needs to Know

Age and history Vital signs GCS score and pupils Alcohol/drugs (s) intake Associated injuries Brain CT

Intracranial Pressure (ICP)

10 mmHg = Normal >10 mmHg = Abnormal >40 mmHg = Severe Many pathologic processes affect outcome ICP brain function, outcome

Cerebral Perfusion
Pressure MBP ICP = CPP Normal: 90 10 = 80 Cushings Response : 100 20 = 80 Shock and Head Injury 50 20 = 30 CPP does not equal cerebral blood flow, cerebral blood flow is the key

Autoregulation
CBF maintained with MBP of 50-160 mmHg Moderate or severe brain injury autoregulation often impaired Brain more vulnerable to episode of hypotension

Cerebral Blood Flow

50 mL/100 g/min = normal < 25 mL/100 g/min = EEG activity 5 mL/ 100 g/min = Cell death

Classifications of Head Injury

By mechanism:

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Classification Cont.
By Severity Mild Head Injury Moderate Head Injury Severe Head Injury

Classification of head injury

Basal skull fracture

CSF rhinorrhea : anterior skull base CSF otorrhea : Mid-skull base Hemotympanum Periorbital ecchymosis Retroauricular ecchymosis Facial nerve injury Loss of hearing Pneumocephalus

Epidural Hematoma
Associated with skull fracture (about 80 %) Classic: middle meningeal artery tear Lenticular / biconvex due to dural adherence to skull Lucid interval

Epidural Hematoma
Can be rapidly fatal Early evacuation, better prognosis Venous epidurals : possible non surgical management in conscious patient or without neurologic abnormality.

Subdural Hematoma
Venous tear / brain laceration Covers entire cerebral surface Morbidity / mortality due to underlying brain injury Rapid surgical evacuation recommended, especially if >5mm shift of midline

Contusion / Hematoma
Coup / contrecoup injuries Most common : frontal / temporal lobes Salt and pepper appearance on CT CT changes usually progressive Most conscious patients : No operation

Concussion
Transient loss of consciousness Normal head CT Nausea, vomiting Headache : if severe, repeat CT Symptoms may worsen before improvement Sequelae common

Diffuse Axonal Injury

Prolonged deep coma (not due to mass lesion) Diffuse brain injury Motor posturing Frequent autonomic dysfunction

Mild Brain Injury

GCS Score = 14 15 History Exclude systemic injuries Neurologic exam X-rays as indicated Alcohol / drug screens as indicated Liberal use of head CT Observe or discharge based on findings

Moderate Brain Injury

GCS Score = 9 13 Initial evaluation same as for mild injury CT-scan for all Admit and observe
Frequent neurologic exams Repeat CT-scan

Deterioration : manage as severe head injury

Severe Brain Injury

GCS Score = 3 8 Evaluation / resuscitate Intubate for airway protection Focused neurologic exam Frequent reevaluation Identify associated injuries

Severe Brain Injury Airway / Breathing

Airway protection Supplemental oxygen Assisted ventilation Modest hyperventilation, if necessary (Paco2 25-35 mmHg) Frequent reevaluation / ABGs

Severe Brain Injury Circulation

Hypotension not due to brain injury Hypotension causes secondary brain injury :
Correct hypotension quickly Do not treat hypertension, maintain CPP

Severe Brain Injury Disability

GCS :
Eye opening Best motor response Verbal response

Pupillary size, equality, reaction to light Symmetry of motor strength

Severe Brain Injury Disability

Minineurologic exam :
On patient arrival After resuscitation Frequently

Document changes Consult neurosurgeon early

Severe Brain Injury Pupillary Findings and Cause

Bilaterally constricted : drugs and pontine lesion
Unilaterally constricted : injured sympathetic pathway

Severe Brain Injury Pupillary Finding and Cause

Bilaterally dilated : 3rd nerve compression and inadequate CNS perfusion Unilaterally dilated : 3rd nerve compression, tentorial herniation and optic nerve injury

Severe Brain Injury Herniation

Deteriorating LOC (GCS score) Pupillary asymmetry Motor asymmetry Cardiopulmonary arrest Cushings triad

Indications for CT-Scan

All patients with suspicion of brain injury

Medical Management
Intravenous fluids :
Euvolemia Isotonic

Hyperventilation, if necessary
Goal : PaCO2 at 35 mmHg

Medical Management
Mannitol
Use with signs of tentorial herniation Dose : 0.5 1.0 g/kg IV bolus

Other
Anticonvulsants Sedation Paralytics

Surgical Management
Scalp Injuries Possible site of major blood loss Direct pressure to control bleeding Occasional temporary closure

Surgical Management
Intracranial Mass Lesion May be life-threatening if expanding rapidly Immediate neurosurgical consult Hyperventilation / mannitol ? Emergency burr holes?

Summary
Prescription (Do) Maintain mean BP >90 mmHg Maintain Paco2 35 mmHg Use isotonic solution for euvolemia Frequent neurologic exams Liberal use of CT-scans Early neurosurgical consult

Summary
Proscription (Dont) Allow patient to become hypotensive Over-aggressively hyperventilate Use hypotonic IV fluids Use long-acting paralytics Paralyze before performing complete exam Depend on clinical exam alone

The Glasgow Coma Scale

Eye opening
Spontaneous Speech To pain None

Verbal response
Orientated Confused conversation Inappropriate words Incomprehensible sounds None

Motor response

Obeys commands Localizes pain Withdraws from pain Abnormal flexion response to pain Extension to pain None