HEAD TRAUMA

Kelompok 2:
Andry Wongso
Rhiza M.I.S
Terri S. S
Priscilla
Pembimbing:
Prof. Dr. dr. M. Z. Arifin, SpBS (K)

Intracranial Pressure
Pressure / Volume Curve
ICP

Herniation

10 point of decompensation
volume of mass

keep the patients pressure & volume

in the flat portion of the curve, rather
than to treat the patient at the point of
decompensation

Increased Intracranial Pressure( IICP )

Result in

Decreased cerebral perfusion

pressure ( CPP )
CPP

: Mean Arterial Blood

PressureICP

Altered level of consciousness

Classification of Head Injury

- Mechanism of injury

Blunt:
automobile collision, fall & assault

Penetrating:
gunshot wounds, other penetrating
injuries

- Severity

Mild:

GCS score 14 ~ 15

Moderate:

GCS score 9 ~13

Severe:

GCS score 3 ~ 8

Skull fractures

Vault:
linear / stellate,
depressed / nondepressed,
open / close
Basilar (diagnosed by CT bone window):
raccoon eyes, Battles signs
(retroauricular ecchymosis),
CSF leakage and 7th nerve palsy

Intracranial Lesions
Focal lesions:
Epidural hematoma:
most due to tearing of the middle meningeal artery
prognosis is usually excellent ( underlying brain
injury is limited )
CT: biconvex or lenticular in shape
Pitfalls: classical lucid interval and talk and die

Intracranial Lesions
Focal lesions
Subdural hematoma:
brain damage much more & prognosis is much
worse than EDH
tearing of a bridging vein

Focal lesions
Contusions and intracerebral hematomas:
most occur in the frontal & temporal
lobes
always seen in association with SDH

Intracranial Lesions
Diffuse injuries
Mild concussion: temporary neurologic dysfunction,
confusion & disorientation without or with amnesia
Classic cerebral concussion:
1.Transient & reversible loss of consciousness, returns
to full consciousness by 6 hrs.
2.No sequelae other than amnesia for the events
3.post-concussion syndrome: memory difficulties,
dizziness, nausea, anosmia & depression

Intracranial Lesions
Diffuse injuries:
Diffuse axonal injury ( DAI )
1.prolonged postraumatic coma that
is not due to a mass lesion or
ischemic insults
2.usually having decortication or
decerebation posture
3.autonomic dysfunction:
hypertension, hyperhidrosis &
hyperpyrexia

Assessment of Head injury

History
Mechanism of injury
Pre and post injury status
Document / communicate
Reassess

Vital Signs
Identifies neurologic & systemic status
Presume hypotension due to hypovolemia,
not head injury

Minineurologic Exam
Purpose
Determine severity of brain injury
Detect deterioration
Categories injuries

Level of consciousness - GCS

eye opening
verbal
motor
Pupil
Motor lateralization ( mass lesion )

Minineurologic Exam
Pupils
Size
Equality
Briskness of response
Anormal: >1 mm difference in size
Extremity Movement
Equality
Pain response
Lateralized weakness - mass lesion

Diagnostic Procedure

CT:
be obtained in all head -injury patients ( ideally ), especially there
is a history of more than a momentary loss of consciousness,
amnesia or severe headaches
C-Spine
Alcohol level & urine toxic screen
Skull X-ray:
penetrating head injury or when CT scan is not immediately
available

Head injury Management

Goal:
To prevent secondary damage
to an already injuried brain
Management Goals
Establish diagnosis
Assure brain metabolism & prevent
secondary brain injury
Consult Neurosurgen early or early transfer

Head injury Management

Management of Mild head injury
Normal CT :
1. Brought back to ER if need ( Head- injury warning
discharge
instructions )
2. No companion ==> Admission or
observe at ER
Abnormal CT : Admission

Head-injury Warning discharge

Instruction

Drowsiness or increasing difficulty in awaking patient ( Awaken patient

every 2 hrs )
Nausea or Vomiting
Convulsion or fits
Bleeding or Watery discharge from the nose or ear
Severe headache
Weakness or loss of feeling in the arm or leg
Confusion or strange behavior
One pupil larger than the other, double vision or visual disturbance
Very slow or very rapid pulse, or an unusual breathing pattern

Head injury Management

Management of Moderate Head Injury
GCS 9 ~ 13
All need brain CT
All need to be admitted, even if CT
scan is normal

Head injury Management

Management of Severe Head Injury
GCS 3 ~ 8
Prompt diagnosis & treatment is of utmost import ( wait and see =
disastrous )
Primary survey : Cardiopulmonary stabilization be achieved rapidly
Secondary survey : >= 50 % had additional major systemic injury
Minineurologic Examination : reliable minineurologic examination
prior to sedating or paralying the patient

Medical Therapies for Head Injury

Intravenous Fluid:
1. Keep euvolemic status, dehydration is
more
harmful ( vital signs stable )
2. Not to use hypotonic or glucose-containing fluids
Hyperventilation:
1. Keep PaCO2 at 25~30 mmHg when the
presence of raised
ICP
2. PaCO2 < 25 mmHg is avoided ( vasoconstriction ==> CBF
)

Medical Therapies for Head Injury

Mannitol:
Indication:
1. Comatous patient who initially has
normal, reactive
pupils, but the develops
pupillary dilatation with or
without
hemiparesis
2. Patient with bilaterally dilated and
nonreactive
pupils who are not
hypotensive
Dose ( bolus ) : 1 g/Kg
Lasix : Be used in consultation with a neurosurgeon

Medical Therapies for Head Injury

Steroid :
Not demonstrated any beneficial effect
Anticonvulsants
High incidence of Late epilepsy:
1. Early seizure occurring within the first week
2. An intracranial hematoma
3. Depressed skull fracture
phenytoin reduce the incidence of seizure in the first week of injury
but not thereafter

TERIMA KASIH

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