Objectives

Describe basic intracranial physiology.

Recognize the importance of limiting
secondary brain injury.
Perform a focused neurologic exam.
Stabilize and arrange for definitive care.

Key Questions
What are the unique features of brain
anatomy and physiology and how do they
affect patterns of brain injury?
What is a focused neurologic exam?
What is optimal management of the
brain-injured patient?
How do I diagnose brain death?

Anatomy and physiology effects?

Rigid, nonexpansile skull filled with
brain, CSF, and blood
CBF autoregulation
Autoregulatory compensation
disrupted by brain injury
Mass effect of intracranial hemorrhage

Intracranial Pressure (ICP)

10 mm Hg =
Normal
> 20 mm Hg =
Abnormal
> 40 mm Hg =
Severe
Many Pathologic Processes affect outcome
Sustained ICP lead to brain function and
outcome

Autoregulation
If autoregulation is intact, CBF is
maintained with a mean BP of 50 to
160 mm Hg.
Moderate or severe brain injury:
Autoregulation often impaired
Brain more vulnerable to episodes of
hypotension secondary brain injury

Classification of Brain injury

By Mechanism
Blunt: High and
low velocity

Penetrating:
GSW and other

Classification of Brain Injury

By Morphology: Skull Fractures
Vault

Depressed / nondepressed
Open / Closed
With / without CSF leak

Basilar

With / without cranial

palsy

Classification of Brain Injury

By Morphology: Brain
Focal

Diffuse

Epidural (extradural)
Subdural
Intracerebral
Concussion
Multiple contusions
Hypoxic / ischemic injury

Diffuse Brain Injury

Mild concussion Severe, ischemic insult

Epidural Hematoma
Associated with skull fracture
Classic: Middle meningeal artery tear
Lenticular / biconvex
Lucid interval
Can be rapidly fatal
Early evacuation essential

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

Contusion / Hematoma
Coup / contracoup injuries
Most common: Frontal / temporal lobes
CT change usually progressive
Most conscious patient: No operation

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
Evaluate and resuscitate
Intubate for airway protection
Focused neurologic exam
Frequent reevaluation
Identify associated injuries

Priorities
ABCDE
Minimize secondary brain injury
Administer O2
Maintain blood pressure
(systolic > 90 mm Hg)

Focused Neurologic Exam?

GCS score
Pupils
Lateralizing signs

Consult neurosurgeon early

Medical Management
Intravenous fluids
Euvolemia
Isotonic
Controlled ventilation
Goal: PaCO2 at 35 mm Hg

Indications for CT Scan?

All patient with

suspicion of brain
injury

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

Medical Management
Other medications
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
Damage control craniotomy: Transfer
to neurosurgeon (rural / austere areas)

Diagnose brain death?

Clinical
GCS Score = 3
Nonreactive pupils
Absent brainstem
reflexes
No spontaneous
ventilatory effort

Ancillary Studies
EEG: No activy
Brain scan: No flow
ICP > Map x 3
hours
No cardiac response
to atropine

Remember, organ donation

: What should I do?

Maintain mean BP > 90 mm Hg
Maintain Paco2 near / at 35 mm Hg
Use isotonic solution for euvolemia
Frequent neurologic exams
Liberal use of CT scans
Early neurosurgical consult

: What should I not do?

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