Committee on Trauma Presents

Head
Trauma
dr. Sri Indah A., Sp.Rad.

ACS

Objectives

Describe basic intracranial

physiology.

Recognize the importance of

limiting secondary brain injury.

Perform a focused neurologic exam.

Stabilize and arrange for definitive

care.
ACS

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
ACS

Monro-Kellie Doctrine
Venous
Volume

Ven.
Vol.

75 mL

Art.
Vol.

Arterial
Volume

Art.
Vol.

Brain

Brain

Brain

CSF

Mass

Mass

CSF

CSF

75 mL

ACS

Volume Pressure
Curve
60555045403530252015105-

Herniation

ICP
(mm Hg)

Point of
Decompensation

Compensation

Volume of Mass

ACS

Intracranial Pressure
(ICP)

10 mm Hg =

Normal

> 20 mm Hg

Abnormal

> 40 mm Hg

Severe

Many pathologic processes affect

outcome

Sustained ICP leads to brain

function and outcome
ACS

Cerebral Perfusion
Pressure*
MBP ICP = CPP
Normal

90

10

80

Cushings
Response

100

20

80

Hypotension

50

20

30

* CPP Cerebral Blood Flow

ACS

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
ACS

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

ACS

Moderate Brain Injury

GCS Score = 9
13

Admit and observe

Initial evaluation
same as for mild
injury
CT scan for all

Frequent neurologic exams

Repeat CT scan

Deterioration:
Manage as severe
head injury
ACS

Severe Brain Injury

GCS Score = 38

Evaluate and resuscitate

Intubate for airway protection

Focused neurologic exam

Frequent reevaluation

Identify associated injuries

ACS

Classifications of Brain
Injury
By Morphology: Brain

Focal

Subdural
Intracerebral

Diffuse

Epidural (extradural)

Concussion

Multiple contusions
Hypoxic / ischemic injury

ACS

Diffuse Brain Injury

Mild concussion Severe,

ischemic insult

Normal CT

Diffuse Injury

ACS

Contusion / Hematoma

Coup / contracoup injuries

Most common: Frontal /

temporal lobes

CT changes usually progressive

Most conscious patients: No

operation
ACS

Contusion / Hematoma

Large frontal
contusion with
shift

ACS

Epidural Hematoma

Associated with skull fracture

Classic: Middle meningeal artery

tear

Lenticular / biconvex

Lucid interval

Can be rapidly fatal

Early evacuation essential

ACS

Epidural Hematoma
Temporal
Epidural
Hematoma
Uncal
herniation

ACS

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
ACS

Subdural Hematoma

ACS

Priorities

ABCDE

Minimize secondary brain injury

Administer O2

Maintain blood pressure

(systolic > 90 mm Hg)

ACS

Focused Neurologic
Exam?

GCS Score

Pupils

Lateralizing signs

Consult neurosurgeon early

ACS

Indications for CT
Scan?
All patients with
suspicion of brain
injury

ACS