Approach to head trauma Dr Abdulaziz Alrabiah, MD Emergency Medicine, Trauma and EMS

Overview is an insult to the brain from an external mechanical force, potentially leading to an altered level of consciousness and permanent or temporary impairment of cognitive, physical, and psychosocial functions. accounts for > 30% of trauma death leading cause of disability under age of 40 years bimodal distribution young adult males elderly

causes Blunt or penetrating Falls (most common cause) MVC (cause of most TBI deaths) violence and assaults industrial accidents sport Consider: NAI in children elder abuse domestic violence

Types Primary Brain injury Primary injury occurs at the time of the traumatic incident —> direct cellular and tissue injury secondary brain injury occurs days after the insult major determinant of neurological outcome further cellular damage

Grading of Head injury Mild GCS 13-15 ‘brief LOC’, nausea, cognitive, behavioural and emotional disturbance Moderate GCS 9-12 after non-surgical resuscitation Severe GCS < 8 after non-surgical resuscitation

GCS

Indication for imaging

Definite indications LOC for > 5 minutes focal neurological findings seizure failure of mental status to improve over time in an alcohol-intoxicated patient penetrating skull injuries signs of a basal or depressed skull fracture coagulopathy previous shunt-treated hydrocephalus infants and children age > 60

New Orleans criteria headache vomiting > 60 yrs drug or alcohol intoxification deficits in STM evidence of trauma above the clavicles

Canadian CT Head rules High risk features GCS < 15 for 2 hours post injury suspected open or depressed skull fracture more than 2 episodes of vomiting physical evidence of basal skull fracture age > 65 coagulopathy

Canadian CT head rules medium risk features antero-grade amnesia for more than 30 min prior to injury dangerous mechanism: pedestrian vs motor vehicle ejection from vehicle fall from > than 3 feet

Types of TBI

Skull Fracture from contact force usually associated with a brief loss of consciousness linear: lateral convexities of skull depressed: blunt force from an object with a small surface area (hammer) compound fracture : open fracture BOS: severe blunt trauma to forehead or occiput

Subdural Haematoma tearing of bridging vein doesn't expand to contralateral hemisphere often associated with cerebral contusion underneath crescent shape ( Moon Shape)

Epidural heamatoma usually from middle meningeal artery tear with associated skull fracture most are temporal or parietal but can occur in frontal and occipital lobes (rare in posterior fossa) classic lenticular shape common in young adult

Subarachnoid haematoma does not produce a haematoma or mass effect may cause post-traumatic vasospasm Star sign

Cerebral contusions heterogenous lesions comprising of punctate haemorrhage, oedema and necrosis do evolve over time (may not see on first CT) can cause significant mass effect with herniation may cause headache -> elevated ICP and coma

Diffuse axonal injury lacerations or punctate contusions at the interface between grey and white matter caused by a rotational vector of injury common cause of persistent vegetative state or prolonged coma

Management of TBI

Seek and Treat ABC intubation if GCS 8 or below treat hypoxia i.e. O2 sat : > 95% treat hypotension i.e. fluid, blood , vasopressor SBP > 90 mmHg , MAP > 65 mmHg

head elevation > 30 degree sedation and analgesia paralysis maintain PaCO2 30-35 mmHg mannitol : 1gm /Kg Hypertonic saline : 3% , 3ml/kg over 30 min de-compressive craniotomy avoid hyperthermia seizure prophylaxis i.e. no evidence of benefit DVT prophylaxis i.e. TEDS, heparin/ clexane within 2-3 days of injury

Thank You aalrabiah@ksu.edu.sa