Head Trauma: Khamim Thohari Rsud DR Muhammad Soewandhie Surabaya

Head Trauma
KHAMIM THOHARI
RSUD DR MUHAMMAD SOEWANDHIE
SURABAYA
Case Scenario
● 58-year-old male fell from a roof in a

small rural town
● Initial GCS score = 12
● On admission after 2-hour transfer,
GCS score is 6
What injuries would you suspect?
What are your priorities in managing this

patient?
Anatomy and Physiology
What are the unique

features of brain anatomy
and physiology, and how
do they affect patterns of
brain injury?
Anatomy and Physiology
Effects
● Rigid, nonexpansile skull filled with brain,
CSF, and blood
● Cerebral blood flow (CBF) usually
autoregulated
● Autoregulatory compensation disrupted by
brain injury
● Mass effect of intracranial hemorrhage
Monro-Kellie Doctrine
Volume-Pressure Curve
Intracranial Pressure (ICP)
10 mm Hg = Normal
>20 mm Hg = Abnormal
>40 mm Hg = Severe
● Sustained increased ICP leads to decreased brain

function and poor outcome
● Hypotension and low saturation adversely affect
outcome
Cerebral Perfusion Pressure
MAP – ICP = CPP
Normal 90 10 80
Cushing’s
100 20 80
Response
Hypotension 50 20 30
Caution
CPP ≠ Cerebral Blood Flow
Autoregulation
● If autoregulation is intact, CBF is

maintained constant between a mean BP of
50 to 60 mm Hg.
● In moderate or severe brain injury,
autoregulation is impaired so CBF varies
with mean BP.
● The injured brain is more vulnerable to
episodes of hypotension, causing
secondary brain injury.
Classifications of Head Injury
By Mechanism of Injury
● Blunt ● Penetrating
High and low GSW and other
velocity
By Morphology – Skull Fractures
Vault
● Depressed / nondepressed
● Open / closed
Basilar
● With / without CSF leak
● With / without cranial nerve palsy
By Morphology – Brain Injuries

Focal
● Epidural (extradural)
● Subdural
● Intracerebral
Diffuse
● Concussion
● Multiple contusions
● Hypoxic / ischemic injury
Epidural Hematoma
● Associated with skull fracture
● Classic: middle meningeal artery tear
● Lenticular / biconvex
● Lucid interval
● Can be rapidly fatal
● Early evacuation essential

Epidural Hematoma
Temporal Epidural Hematoma
Uncal herniation
Subdural Hematoma
● Venous tear / brain laceration

● Covers cerebral surface
● Morbidity / mortality due to
underlying brain injury
● Rapid surgical evacuation
recommended, especially if > 5 mm
shift of midline
Subdural Hematoma
Intracerebral Hematoma / Contusion
● Coup / contracoup injuries
● Most common: frontal / temporal lobes
● CT changes usually progressive
● Most conscious patients: no operation

Intracerebral Hematoma / Contusion
Large Frontal Contusion with Shift

Diffuse Brain Injury
Normal CT Diffuse Injury
● Range from mild concussion to severe ischemic

insult
By Severity of Injury Based on GCS Score
● Mild
● Moderate
● Severe
Mild Brain Injury
● GCS score = 13 – 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 – 12
● 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
● Evaluate and resuscitate
● Intubate for airway protection
● Focused neurologic exam
● Frequent reevaluation
● Identify associated injuries

Indications for CT Scan
High Risk
● GCS score still < 15 two hours after injury

● Neurologic deficit
● Open skull fracture
● Sign of basal skull fracture
● Extremes of age
Moderate Risk
● “Dangerous mechanism”
● Retrograde amnesia > 30 minutes in duration
● Severe headache
● Vomiting > 2 episodes
Management
Priorities
● ABCDE
● Minimize secondary brain injury
● Administer oxygen
● Maintain adequate ventilation
● Maintain blood pressure
(systolic > 90 mm Hg)
Management
Focused Neurological Exam

● GCS score
● Pupils
● Lateralizing signs
Consult
neurosurgeon
early
Management
Medical
● Controlled ventilation
● Goal: Paco2 at 35 mm Hg
● Intravenous fluids
● Euvolemia
● Isotonic
● Consult with neurosurgeon
● Mannitol
● Use with signs of tentorial herniation
● Dose: 0.25 to 1.0 g / kg IV bolus
Management
Medical
● Other medications
● Anticonvulsants
● Sedation
● Paralytics
Neurological examination before

prolonged sedation / paralysis
Management
Surgical
● Scalp Wounds
● Possible site of major blood loss
● Direct pressure to control bleeding
● Occasional temporary closure
Management
Surgical
● Intracranial Mass Lesion
● Can be life-threatening if expanding rapidly
● Immediate neurosurgical consult
● Hyperventilation / mannitol
● Damage control craniotomy: transfer to neurosurgeon
(rural / austere areas)
Summary
● Ensure adequate oxygenation

● Maintain Paco2 near / at 35 mm Hg
● Maintain mean BP > 90 mm Hg
● Frequent neurologic assessment
● Liberal use of CT
● Early neurosurgical consult

Head Trauma: Khamim Thohari Rsud DR Muhammad Soewandhie Surabaya

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Head Trauma

● 58-year-old male fell from a roof in a

What injuries would you suspect?

What are your priorities in managing this

What are the unique

● Sustained increased ICP leads to decreased brain

MAP – ICP = CPP

● If autoregulation is intact, CBF is

By Morphology – Skull Fractures

By Morphology – Brain Injuries

● Associated with skull fracture

● Classic: middle meningeal artery tear

● Can be rapidly fatal

● Early evacuation essential

Temporal Epidural Hematoma

● Venous tear / brain laceration

● Coup / contracoup injuries

● Most common: frontal / temporal lobes

● CT changes usually progressive

● Most conscious patients: no operation

Large Frontal Contusion with Shift

Normal CT Diffuse Injury

● Range from mild concussion to severe ischemic

By Severity of Injury Based on GCS Score

Observe or discharge based on findings

● Evaluate and resuscitate

● Intubate for airway protection

● Focused neurologic exam

● Identify associated injuries

● GCS score still < 15 two hours after injury

Focused Neurological Exam

Neurological examination before

● Ensure adequate oxygenation

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