Armando Hasudungan
Biology and Medicine videos

Head and Brain Trauma

Overview Traumatic Brain Injury – classified as mild, moderate or severe based on GCS Concussion Cerebral contusion (intracerebral haemotoma) Subarachnoid Haemorrhage Subdural Haemorrhage Epidural Haemorrhage Diffuse axonal Injury PAMD Preparation Assessment – Primary Survey Management Assessment – Secondary Survey Dislocation Preparation Staff Equipment  Assessment – Primary Survey – ABCDE Airway – Patent and Protected Foreign […]

Overview

  • Traumatic Brain Injury – classified as mild, moderate or severe based on GCS
  • Concussion
  • Cerebral contusion (intracerebral haemotoma)
  • Subarachnoid Haemorrhage
  • Subdural Haemorrhage
  • Epidural Haemorrhage
  • Diffuse axonal Injury

PAMD

  • Preparation
  • Assessment – Primary Survey
  • Management
  • Assessment – Secondary Survey
  • Dislocation

Preparation

  • Staff
  • Equipment

 Assessment – Primary Survey – ABCDE
  • Airway – Patent and Protected
    • Foreign bodies
    • Facial, mandibular, or tracheal/laryngeal fractures
Remember If the patient is able to communicate verbally, the airway is usually patent
  • Breathing – Look, listen, feel
    • Identify any life-threatening conditions affecting thorax
      • Tension pneumothorax
      • Flail Chest
Side note Ventilation may be reduced for a number of reasons, (1) diaphragm fatigue, (2) Progressively ascending spinal cord damage from primary damage or secondary ascending spinal cord oedema encroaching on C3-C5, (3) These same segments may be involved from primary injury and diaphragm may be partially paralysed and (4) Consequence of co-existing chest trauma
  • Circulation
    • HR, BP, Capillary refill, skin colour
    • Look for signs of shock or unstable rhythm
    • Hypotensive trauma victims should be considered as intravascularly volume depleted and bleeding until proven otherwise
  • Disability
    • GCS
    • Pupils – equal and reactive
    • Neurological examination – motor and sensory
    • Suspect C-spine injury until ruled out
    • Check for signs of ↑ICP – Cushing’s response (bradycardia, hypertension, irregular respirations)
Remember A dilated pupil in an unconscious patient with head trauma is evidence of transtentorial herniation caused by downward pressure on the uncus and ipsilateral 3rd cranial nerve.
  • Exposure/Environment
    • Increased risk of hyperthermia due to peripheral vasodilation
    • Look for other injuries
      • Fractures – Basilar skull fracture?
      • Scalp laceration
      • Burns
Warning Signs of Severe Head Injury
GCS <8
Deteriorating GCS
Unequal pupils
Lateralizing signs

 

INVESTIGATIONS
Laboratory Imaging
FBC X-Ray – Neck, Thorax, Pelvis
EUC Head CT scan (non-contrast)
Cross match Ultrasound (FAST)?
Urinalysis MRI – axonal injury is suspected
Pregnancy test Angiogram?
Serum lactate
Glucose

Management – The aim is to reduce secondary brain injury

  • Airway – Patent and Protected
    • Insertion of nasogastric tube important to minimise likelihood of aspiration
    • Ensure oxygen delivery to brain through intubation and prevent hypercarbia
      • Intubate if GCS < 9, patient is hypoxic, injury at or above C4′
    • Oxygen!
Remember Avoid secondary brain injury by preventing hypotension, hypoxia, fever, seizures and hyperglycaemia
  • Breathing – Look, listen, feel
    • Consider diaphragm issues (injury at C3, C4, C5)
    • Identify and treat life threatening chest injury
    • In the absence of major airway obstruction and flail chest, the presence of paradoxical breathing is considered highly suggestive of cervical spine injury
  • Circulation
    • Look for signs of shock or unstable rhythm
    • 2 large IV insertion
    • If hypotensive – IV crystalloids, avoid albumin
    • If seizure/risk – benzodiazepines, phenytoin, phenobarbital
  • Disability
    • GCS
    • Pupils – equal and reactive
    • Neurological examination – motor and sensory
    • Spinal immobilisation until spinal cord or unstable vertebral injury has been excluded on physical examination and investigations (using nexus criteria as an example)
    • If signs of increased intracranial pressure
      • Calm (sedate) if risk for high airway pressures or agitation – paralyze if agitated
      • Elevate head of bed
      • Hyperventilate (100% O2) to a pCO2 of 30-35 mmHg
      • Adequate BP to ensure good cerebral perfusion
      • Mannitol 1g/kg infused rapidly (contraindicated in shock/renal failure
      • Surgical – decompression, drainage
Remember for raised ICP make sure to control perfusion, glucose, temperature and seizures
  • Exposure/Environment
    • Increased risk of hyperthermia due to peripheral vasodilation
      • Warm IV fluids
      • Warm blankets
    • Look for other injuries
Remember Consult the neurosurgeon early and aggressively treat hypoxia, hypotension, herniation, and seizures to avoid secondary (preventable) injuries

Early and Late signs of Head trauma

Assessment – Secondary Survey (Head to Toe) – Once patient is stabilised

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