ATLS - Head Trauma Modified

Committee on Trauma Presents
Head
Trauma
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 = 1415
X-rays as indicated
History
Exclude systemic
injuries
Alcohol / drug
screens as indicated
Liberal use of head

CT
Neurologic exam
Observe or discharge based on findings
ACS
Moderate Brain Injury
GCS Score = 913
Admit and observe
Initial evaluation
same as for mild
injury
Frequent neurologic exams

Repeat CT scan
CT scan for all
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
Medical Management
Intravenous fluids
Euvolemia
Isotonic
Controlled ventilation
Goal: Paco2 at 35 mm Hg
ACS
Medical Management
Mannitol
Use with signs of tentorial herniation
Dose: 1.0 g / kg IV bolus
Consult with neurosurgeon first
ACS
Medical Management
Other medications
Anticonvulsants
Sedation
Paralytics
ACS
Surgical Management
Scalp Injuries
Possible site of major blood loss
Direct pressure to control bleeding
Occasional temporary closure
ACS
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)
ACS
ACS
Summary: 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

ACS
Summary: 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

ACS

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Committee on Trauma Presents

Describe basic intracranial physiology.

Recognize the importance of limiting

Perform a focused neurologic exam.

Stabilize and arrange for definitive care.

Anatomy and physiology effects?

Rigid, nonexpansile skull filled with

Mass effect of intracranial hemorrhage

Volume Pressure Curve

Intracranial Pressure (ICP)

Many pathologic processes affect outcome

Sustained ICP leads to brain function and

Cerebral Perfusion Pressure*

* CPP Cerebral Blood Flow

If autoregulation is intact, CBF is

Moderate or severe brain injury:

Brain more vulnerable to episodes of

Mild Brain Injury

GCS Score = 1415

Liberal use of head

Observe or discharge based on findings

Moderate Brain Injury

GCS Score = 913

Admit and observe

Frequent neurologic exams

CT scan for all

Deterioration: Manage as severe

Severe Brain Injury

Evaluate and resuscitate

Intubate for airway protection

Focused neurologic exam

Identify associated injuries

Classifications of Brain Injury

Diffuse Brain Injury

Mild concussion Severe, ischemic

Coup / contracoup injuries

Most common: Frontal / temporal lobes

CT changes usually progressive

Most conscious patients: No operation

Associated with skull fracture

Classic: Middle meningeal artery tear

Can be rapidly fatal

Early evacuation essential

Venous tear / brain laceration

Covers cerebral surface

Morbidity / mortality due to underlying

Rapid surgical evacuation

Minimize secondary brain injury

Maintain blood pressure

Focused Neurologic Exam?

Consult neurosurgeon early

Indications for CT Scan?

All patients with

Use with signs of tentorial herniation

Dose: 1.0 g / kg IV bolus

Consult with neurosurgeon first

Possible site of major blood loss

Direct pressure to control bleeding

Occasional temporary closure

May be life-threatening if expanding rapidly