Head Injury

Last Updated on by frcemuser

Different types of traumatic brain injury

 

Extradural haemorrhage (aka epidural haemorrhage)

  • Relativély uncommon
  • May have a lucid period and deteriorate rapidly
  • usually? associated with a skull fracture
  • Mostly arterial but venous
  • 70-80% middle meningeal artery
  • Biconvex on CT
  • It May be fatal within hours

Subdural haemorrhage

  • More common — especially in the presence of cerebral atrophy (e.g. elderly and alcoholics)
  • May present as acute or chronic
  • Concave shaped on CT- Hyperdense
  • Venous bleeding
  • Mortality 60 to 80%

Chronic Subdural

  • Venous bleeding
  • More common with brain shrinkage (e.g. age or alcohol)
  • More common on anticoagulants
  • Present weeks after the injury
  • Presents similar to a stroke but nausea, vomiting and headache may also be present
  • CT scan may show layering

Intracerebral haemorrhage/Contusions

  • Ranging from contusions to hematoma
  • do evolve over time (may not see on first CT) -> can cause a significant mass effect with herniation
  • Some advocate observation and/or repeat scanning in 24-48 hours
  • may cause a headache -> elevated ICP and coma.

Depressed skull fracture

  • Often associated with
  • underlying brain injury
  • If depressed may need to be elevated
  • Associated with later epilepsy

Basal skull fracture

  • ‘Racoon’ eyes
  • Battle:s sign (mastoid bruising)
  • Subconjunctival haemorrhage
  • Haemotympanum

Signs of raised ICP include:

  • Reduced or fluctuating consciousness
  • Pupillary signs (irregularity or dilatation in one eye)
  • Focal neurology
  • CN III palsy
  • Contralateral hemiparesis
  • Cushing’s triad: hypertension, bradycardia and irregular breathing
  • Cardiorespiratory arrest

Management

  • Activate the trauma team
  • Airway maintenance with cervical spine immobilization
    • intubate if GCS <8
    • consider intubating patients with higher GCS if agitated, hypoxic or hypoventilating
    • avoid nasopharyngeal airways due to the risk of intracranial passage
    • maintain cervical spine precautions
  • Breathing and ventilation
    • high flow oxygen 15L/min via a non-rebreather mask
    • target PaCO2 4.5 – 5.0 kPa (34-38mmHg) (low-normal range)-  normocarbia is preferred. Avoid Hypercarbia (PCO2 > 6.0 kPa)- Vasoconstriction- Increase ICP
    • hyperventilation (PaCO2 of 4.0 to 4.5 kPa) only Brief periods of hyperventilation (PaCO2 of 4.0 to 4.5 kPa) may be necessary to manage acute neurological deterioration while other treatments are initiated. Hyperventilation will lower ICP in a deteriorating patient
  • Circulation with haemorrhage control
    • Target MAP of 70 mmHg to maintain adequate CPP (CPP -50 – 70mmHg). some advise MAP 80-90 mmHg to allow for variations during resuscitation
    • Avoid permissive hypotension in trauma patients with significant head injuries.
    •  monitor serum sodium levels in patients with head injuries. Hyponatraemia – Edema
    • Rapid normalisation of anticoagulation is generally required.
  • Disability (neurological evaluation)
    • assess GCS, pupils and motor and sensory function in all limbs prior to sedation or intubation
    • suspect critically raised intracranial pressure if Cushing’s response (bradycardia, hypertension, apneas), fixed and dilated pupil(s), hemiparesis.
    • treat suspect critically raised intracranial pressure: head up 30 degrees, remove neck constrictions, administer mannitol 20% solution (20 g of mannitol per 100 ml of solution) or 3% hypertonic saline according to local guidelines, urgently liaise with neurosurgery
    • Treat seizures and consider prophylactic anticonvulsants according to local guidelines.
  • Exposure and Environmental Control
    • maintain T36-37; give antipyretics if T>38C
  • Consider transfer: Organize early transfer to a neurosurgical unit
  • Secondary survey:
    • Head-to-toe examination looking for other injuries
    • organize the CT head to define the nature of the traumatic brain injury
  • Post-resuscitation care and monitoring (Adequate oxygenation, Avoid hypoventilation, Avoid hypotension, Maintain normal intracranial pressure, Normal glucose)
    • Pa02 > 13 kPa (98mmHg)
    • PaC02 of 4.5 – 5.0 kPa (34-38mmHg)
    • MAP 80 mmHg
    • Glucose 4 — 8 mmol/l
    • Temperature < 37 Deg C
    • With ICP monitoring
      • CPP -50 – 70mmHg
      • ICP < 20mmHg

Cerebral perfusion pressure = mean arterial pressure (MAP) – mean intracranial pressure

Indication for CT Brain – after a trauma

Observation:

  • after the initial assessment in the emergency department half-hourly for 2 hours, 1-hourly for 4 hours, and 2-hourly thereafter.

Discuss with neurosurgery regardless of imaging if:

  • CSF leak
  • progressive focal neurology
  • Penetrating head injury
  • GCS <8, persistent confusion
  • seizure without full recovery

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