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 bodies
  • Facial, mandibular, or tracheal/laryngeal fractures

• Breathing – Look, listen, feel
  • Identify any life-threatening conditions affecting thorax
    • Tension pneumothorax
    • Flail Chest

• 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)

• Exposure/Environment
  • Increased risk of hyperthermia due to peripheral vasodilation
  • Look for other injuries
    • Fractures – Basilar skull fracture?
    • Scalp laceration
    • Burns

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!

• 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

• Exposure/Environment
  • Increased risk of hyperthermia due to peripheral vasodilation
    • Warm IV fluids
    • Warm blankets
  • Look for other injuries

Early and Late signs of Head trauma

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