HEAD TRAUMA


General Principles
  1. Diagnostic Pearls
     
    1. Assume c-spine injury
      • Maintain c-spine precautions
    2. Examine Head
      • Depressed skull fracture
      • Basilar skull fracture
        • Battle's sign - bilateral mastoid ecchymosis
        • Raccoon eyes - bilateral periorbital ecchymosis
        • CSF, rhinorrhea, otorrhea, hemotympanum
      • Scalp lacerations
      • Major facial trauma
      • Maxillofacial trauma
    3. Neuro evaluations
      • Serial Glasgow Coma Scale  assessments
      • Neuro exam
        • DTR's, Babinski's
        • Motor function
        • Sensory function (pain, position, light touch, vibration)
        • Consider cold calorics & doll's eyes to assess brainstem activity
          • Clear c-spine first
          • R/O ruptured TM (after c-spine cleared)
      • RECHECK PUPILS AND NEURO EXAM FREQUENTLY!!!
         
    4. Pupil abnormalities
      • Single "blown" pupil:
        • Herniation, Horner's syndrome
        • Prior eye injury or surgery
        • Eyedrops (Mydriatics)
           
      • Bilateral "blown" pupils:
        • Hypoxia, hypothermia, hypotension
        • Eyedrops (Mydriatics)
        • Atropine
           
      • Pinpoint pupils:
        • Pontine dysfunction/ infarct, uveitis
        • Narcotics
        • Eyedrops (Myotics)
           
    5. Breathing patterns
      • Cheyne-Stokes: (periodic breathing)-cortical dysfunction
      • Cluster respirations: pontine dysfunction
      • Ataxic respirations (totally irregular) usually preterminal
    6. Herniation syndromes
      • Transtentorial (Uncal) herniation
        • Most commonly seen herniation
        • Medial aspect of temporal lobe migrates across tentorium
        • Declining mental status
        • Blown unilateral pupil
          • Classic 1st warning sign
          • 80% on side of herniation
        • Contralateral Babinski reflex
        • Contralateral then ipsilateral hemiplegia
        • Sustained hyperventilation
        • Bilateral decerebrate (extension) posturing
        • Brainstem becomes compressed
          • Bilateral blown pupils
          • No brainstem reflexes
      • Central herniation
        • Diffuse increase in ICP
        • Each hemisphere is displaced through tentorium
          • Significant pressure put on upper brainstem
        • Signs
          • Behavior and/or alertness changes
          • Frequent sighs or yawns
          • +/- Cheyne-Stokes respiration
          • Miotic reactive pupils
          • +/- roving eye movement progressing to bilateral blown pupils
          • Extremity rigidity, THEN
          • Decorticate (flexion) posturing, THEN
          • Decerebrate posturing
      • Posterior fossa (Tonsillar) herniation
        • Increased pressure develops in posterior fossa
        • Cerebellar tonsils displaced down through foramen magnum
        • Lower brainstem and upper cervical cord are compressed
        • Signs:
          • Coma
          • Bradycardia
          • Respiratory arrest
        • Mortality is 70%
      • Cerebellar (upward) herniation
        • Increased pressure or large mass in posterior fossa
        • Cerebellum displaced upward through tentorial opening
        • Causes compression of upper brainstem
        • Signs
          • Rapid decrease in level of consciousness
          • Pinpoint pupils (pontine compression)
          • Downward conjugate gaze
          • Absence of vertical eye movements
      • Subfalcine herniation
        • Cingulate gyrus displaced across midline under free edge of falx
        • Can compromise blood flow in ant. cerebral artery complex


     

  2. Management Concerns
     
    1. ABCs
      • Maintain inline c-spine immobilization when intubating
    2. IV, O2, cardiac monitor, labs, pulse oximetry
    3. Intubation (presume elevated ICP)
      • Pretreatment (2-3 minutes before intubating)
        • Lidocaine: 1.5 mg/kg IV
          • To prevent incr ICP
        • Vecuronium; 0.01 mg/kg IV
        • Fentanyl: 3 mcg/kg IV (over 1 min)
      • Induction/ Paralysis
        • Etomidate: 0.3 mg/kg IV
        • Succinylcholine: 1.5 mg/kg IV
    4. CT for any traumatic LOC as soon as pt is stable
    5. Closely follow
      • Pulse-ox, respiratory pattern
      • BP, HR
      • Pupil exam
      • Response to pain & commands
    6. For decreased MS
      • Re-evaluate patient
        • Consider increased ICP
      • Consider Narcan 1-2 mg IV: dilute in 10-20 cc syringe
      • Consider Flumazenil: 0.2 mg then 0.3 mg IV
      • Check Glucose (Accu-Check)
    7. Seizures
      • Acute seizure management
        • Diazepam 5-10 mg IV to stop seizures
      • Prophylaxis
        • Phenytoin 1 g IV for prophylaxis & treatment (fosphenytoin)
      • Prolonged seizures
        • Phenobarb 1 g IV
          • May alter neuro exam
    8. Early neurosurgery involvement
    9. Watch for signs of increased ICP
      • Change in mental status, hypotension
      • Decr GCS by 3
      • HA, nausea, vomiting, papilledema
      • Cushing reflex (pre-terminal: bradycardia, hypertension & decr RR)
    10. Treat increased ICP
    11. For herniation
      • Burr hole placement to relieve incr ICP (performed by neurosurgeon)
      • Elevate head if C-spine cleared
      • Hyperventilate
      • Mannitol
    12. Subarachnoid hemorrhage (SAH)
      • In adult pts w/ HA w/o focal neurological deficits
        • Negative CT & negative LP (< 5 rbc's/┬ÁL) essentially excludes SAH
          • Reduces probability 10% to 0.0001%


 

  TYPE OF PATIENT ANATOMIC LOCATION CT FINDINGS COMMON CAUSE CLASSIC SYMPTOMS
Epidural Most common in young adults, rare in the elderly Potential space between skull and dura mater Biconvex, football-shaped hematoma Skull fracture with tear  of the middle meningeal artery Immediate LOC with a "lucid" period prior to deterioration (only occurs in about 20% of patients)
Subdural More risk for the elderly & alcoholics Space between dura mater and arachnoid Crescent - or sickle-shaped hematoma Acceleration - deceleration with tearing of the bridging veins Acute: Rapid LOC - lucid period possible
Chronic: Altered MS & behavior with gradual decrease in consciousness
Subarachnoid Any age group following blunt trauma. Subarachnoid Blood in the basilar cisterns & hemispheric sulci & fissures Acceleration - Deceleration w/ tearing of the subarachnoid vessels Milt to moderate TBI w/ meningeal signs & symptoms
Contusion/
intracerebral hematoma
Any age group following blunt trauma. Usually anterior temporal or posterior frontal lobe May be normal initially with delayed bleed Severe or penetrating trauma, shaken-baby syndrome Symptoms range from normal to unconscious.
Abbreviations: LOC = loss of consciousness; MS = mental state; TBI = traumatic brain injury.