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Management of the
Head Injury Patient
William Schecter, MD
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Epidemilogy
• 1.6 million head injury patients in the U.S.
annually
• 250,000 head injury hospital admissions
annually
• 60,000 deaths
• 70-90,000 permanent disability
• Estimated cost: $100 billion per year
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Causes of Brain Injury
• Motor Vehicle Accidents
• Falls
• Anoxic Encephalopathy
• Penetrating Trauma
• Air Embolus after blast injury
• Ischemia • Intracerebral hemorrhage from Htn/aneurysm
• Infection • tumor
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Brain Injury
• Primary Brain Injury
• Secondary Brain Injury
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Primary Brain Injury
• Focal Brain Injury
– Skull Fracture
– Epidural Hematoma
– Subdural Hematoma
– Subarachnoid Hemorrhage
– Intracerebral Hematorma
– Cerebral Contusion
• Diffuse Axonal Injury
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Fracture at the Base of the
Skull
• Periorbital Hematoma
• Battle’s Sign
• CSF Rhinorhea
• CSF Otorrhea
• Hemotympanum
• Possible cranial nerve
palsy
Fracture of maxillary sinus causing CSF Rhinorrhea
Battle’s Sign
images/-http://health.allrefer.com/pictures
battles-sign-behind-the-ear.html
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Skull Fractures
Linear and Depressed Normal Depressed
Non-depressed vs Depressed
Open vs Closed
Linear vs Egg Shell
http://www.emedicine.com/med/topic2894.htm
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Temporal Bone Fracture
http://www.vh.org/adult/provider/anatomy/
AnatomicVariants/Cardiovascular/Images0300/0386.html
http://www.bartleby.com/107/illus510.html
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Epidural Hematoma
http://www.bartleby.com/107/illus769.html http://www.chestjournal.org/cgi/content/full/122/2/699
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Epidural Hematoma
• Uncommon (<1% of all head injuries, 10% of post traumatic coma patients)
• Located between the dura and the skull
• Often associated with temporal bone fracture
• ―Classic Presentation‖ = Unconsciousness followed by a lucent period followed by deterioration
• Look for ipsilateral pupillary dilation
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Third Nerve Palsy
• Constricts pupil
• Innervates levator
palpebrae of the
eyelid
• Innervates superior,
medial and inferior
rectus muscles of eye
• Pupillary Dilation
• Drooping eyelid
Function of Third Nerve Physical Finding
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Third Nerve Palsy
• Physical Findings
– Dilated Pupil
– Drooping Eyelid
• Look for Cushing’s Reflex (elevated ICP)
– Hypertension
– Bradycardia
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Case Presentation
• 17 year old girl stuck by a car. Transient loss of consciousness at the scene. Scalp laceration.
• Awake and responding in the ER. No CT available. To OR for repair of scalp laceration under local anesthesia.
• The next morning speaking in English and Samoan
• Drowsey at 16:00
• 16:45: Bilateral dilated pupils and respiratory distress
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Epidural Hematoma
•Uncommon (less than 5% of cases)
•Classic Findings
–Initial Loss of Consciousness
–Lucid Interval
–Neurological Deterioration
•Associated with tear of Middle Meningeal Artery
•Prognosis good if timely diagnosis and treatment
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Subdural Hematoma
• Bleeding between the
dura and the brain
• Results from tearing
of ―bridging veins‖
• Subdural hematoma
may be
– Acute
– chronic
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Case Presentation
• 35 year old man involved in an automobile accident on a Sunday afternoon at approximately 12:00 noon. Admitted with altered mental status, hemodynamically stable. No major injuries except acute SDH
• No neurosurgeon available. Transferred to 2 other hospitals w/o neurosurgeons
• 6 hours after accident arrives at San Francisco General Hospital with bilateral fixed and dilated pupils
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Acute Subdural Hematoma
http://www.emedicine.com/EMERG/topic560.htm http://www.neuroanatomy.hpg.ig.com.br/brain.htm
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Acute Subdural Hematoma
•50% Mortality
•Return to normal function limited in
survivors
•More common in older patients
•Prevention of Secondary Brain Injury
essential
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Case Presentation
• 45 year old radiologist arrives for dinner at
colleagues’ house for dinner complaining
of head ache. Neurological exam normal.
• Admitted later in the evening for dizziness.
Signs out of hospital AMA the next
morning. No CT available.
• Returns that afternoon. The next day
unconscious with slightly dilated left pupil.
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Chronic Subdural Hematoma
http://www.radiology.co.uk/srs-x/tutors/cttrauma/tutor.htm#subdural
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Chronic Subdural Hematoma
•3-6% Mortality Rate
•Normal return to neurologic function if
diagnosis made early in 65-75% of cases
•High index of suspicion in chronic
alcoholics, the elderly, patients on
anticoagulant therapy
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Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
After Karate Kick to the Head
40-70% of patients with
post traumatic subarachnoid
hemorrhage results in severe
neurologic disability or death
http://bmj.bmjjournals.com/cgi/content/full/308/6944/1620/F11
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Cerebral Contusion
• Ipsilateral - Coup
• Contralateral – Contrecoup
• Clinical Findings depend on location and
severity of the contusion
• CT Findings
– No findings
– Localized swelling of the gyri
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Intraparenchymal Hematoma
• Similar to CNS mass lesion
• Decision to evacuate vs observe difficult
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Diffuse Axonal Injury
• Mechanical Shearing as a
result of deceleratioon
resulting in tearing of axons
• Almost 50% of patients with
severe head injury have
DAI
• Process may extend due to
Secondary brain injury
• 90% of survivors remain in
a persistent vegetative state http://www.emedicine.com/radio/topic216.htm
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Primary Brain Injury
• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid Hemorrhage
• Cerebral Contusion
• Intracerebral Hematoma
• Diffuse Axonal InjuryS
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Secondary Brain Injury
• Area of original injury extended due to
– Cerebral edema
– Ischemia
– Infection
– Herniation
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Goal
Prevention of Secondary Brain Injury by Controlling
Intracranial Pressure, Maintaining Cerebral
Perfusion and Oxygenation
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Cerebral Perfusion Pressure
• Adequate CPP essential for prevention of
Secondary Brain Injury
• CPP = MAP – ICP
• CPP should be > 70-80 mm Hg
• Systemic Hypotension leads to poor
neurological outcome
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Intracranial Pressure
• Monroe-Kelly Doctrine (early 19th century)
– intracranial volume (constant) = brain
volume + CSF volume + blood volume +
mass lesion volume
0
2
4
6
8
10
12
14
16
18
Volume
Pressure
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Signs of increased ICP
•Headache
•Nausea and vomiting
•Change in level of consciousness
•Seizures
•Change in pattern of ventilation
•Papilledema (not after acute trauma)
•Change in motor function
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Indications for ICP Monitoring
• Severe Head Injury (GCS 3-8)
• Moderate Head Injury (GCS 9-12)
– Particularly if abnormal CT Scan
• Mild Head Injury (GCS 13-15) – little
indication for ICP Monitoring
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Methods to Control ICP
•Elevate Blood Pressure
–Judicious volume expansion
–Vasoactive drugs
•Hyperventilation—NO!!!!!
–Maintain pC02 around 35 mmHg
•Diuretics
–Mannitol
–Use with caution after neurosurgical consultation
•Drainage of CSF from Ventriculostomy Catheter
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Maintain CPP
• Raise MAP
– Volume
– Vasopressors
• Decrease ICP (if > 20 mm Hg)
– Hyperventilation (not recommended)
– CSF Drainage
– Mannitol (use with caution) 1 gram/kg over 30
minutes
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Management of the Head Injury
Patient • Primary Survey
– Airway
• CERVICAL SPINE CONTROL (5-10% of head injuries
associated with cervical spine fracture
• Glascow Coma Scale < 8 – indication for intubation
– Circulation
• Rapidly treat hypotension
– Disability
• Glascow Coma Scale
• Pupils
• ? Moves all 4 extremities
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Glascow Coma Scale
6
5
4
3
2
1
Obeys
Localizes pain
Withdraws from pain
Abnormal Flexion
Abnormal Extension
No Response
Best Motor
Response
5
4
3
2
1
Oriented and converses
Disoriented and converses
Inappropriate words
Incomprehensible sounds
No response
Best
Verbal
Response
4
3
2
1
Open Spontaneously
To verbal command
To pain
No response
Eyes
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Eyes
•Open spontaneously – 4
•Open to verbal stimulus – 3
•Open to Pain -- 2
•Unresponsive -- 1
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Verbal Response
•Converses appropriately – 5
•Converses but confused – 4
•Speaks only words but not sentences – 3
•Sounds but no words – 2
•No verbal response – 1
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Motor Response
•Responds to commands – 6
•Responds to pain with localization – 5
•Responds to pain with withdrawal –4
•Responds to pain with flexion – 3
•Responds to pain with extension – 2
•Unresponsive – 1
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Neurologic Exam during Secondary
Survery
• (GCS) Mental Status
• Cranial Nerve Exam (pupils!!)
• Motor Exam of Upper and Lower
Extremities
• Sensory Exam
• Reflexes (Babinski Sign?)
• Gait and Station/Ataxia (rarely done in the
acute situation
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Potential Abnormalities in
Secondary Survey
•Hypertension and Bradycardia– Cushing’s
Reflex
•Cheyne Stokes Respiration in comatose
patient-abnormal function of the Medulla
Oblongata
•Asymmetric pupils—Uncal herniation vs
Direct blow to the orbit
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Potential Abnormalities in
Secondary Survey
•Asymmetric movement of the left vs the
right extremities– intracranial mass lesion
vs local injury
•Asymmetric movement of the upper vs the
lower extremities--? Spinal cord injury
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Deterioration in Neurologic
Exam?
Repeat CT Scan
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Additional Therapy for the Head
Injury Patient
• Phenytoin 15 mg/kg over 30 minutes with
EKG monitor if signs of seizure activity.
Prophylactic Treatment to prevent
seizures not recommended
• Steroids: Not recommended
• Barbiturate Coma: In selected cases with
uncontrollable Intracranial Hypertension
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Brain Injury
• Primary Brain Injury
• Secondary Brain Injury
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Primary Brain Injury
• Focal Brain Injury
– Skull Fracture
– Epidural Hematoma
– Subdural Hematoma
– Subarachnoid Hemorrhage
– Intracerebral Hematorma
– Cerebral Contusion
– Diffuse Axonal Injury
• Secondary Brain Injury
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Secondary Brain Injury
• Area of original injury extended due to
– Cerebral edema
– Ischemia
– Infection
– Herniation
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Goal
Prevention of Secondary Brain Injury by Controlling
Intracranial Pressure, Maintaining Cerebral
Perfusion and Oxygenation