Head Trauma

Anatomy of Nervous System The nervous system is composed of Brain Spinal cord The nervous system is divided into: Central nervous system (Brain & Spinal Cord) Peripheral nervous system

Superior view of the skull

Physiology of Nervous System Cerebral Blood Flow (CBF) Main Arterial Pressure (MAP) Intracranial Pressure (ICP) Cerebral Perfusion Pressure (CPP) CPP = MAP – ICP

Injuries to the Brain & Skull Scalp injuries Skull injuries Brain injuries

Scalp Injuries Scalp has many blood vessels so injury may bleed profusely. Control bleeding with direct pressure. Don’t apply pressure when there is possible skull injury.

Anatomy of skull

Injuries to the scalp

Scalp injuries

Scalp injuries

Skull injuries It include fractures to the cranium and the face, can be associated with brain injury. It is divided into: Open skull fracture: cranium is fractures and scalp is lacerated. Closed skull fracture: scalp is lacerated but cranium is intact. Basal skull fracture

S & S of Skull Fractures and Brain Injuries Visible bone fragments Altered mental status Deep lacerated or severe bruise or hematoma Depression or deformity of the skull Severe pain at site of injury Battle’s Sign Unequal or unreactive pupils Raccoon’s eye Sunken eye Bleeding from the ears and/or nose Clear fluid flow from ears and/or nose Personality change Increased blood pressure, decreased pulse rate and widening pulse pressure (Cushing’s Syndrome) Irregular breathing pattern Temperature increase Blurred or multiple vision Impaired hearing or ringing Equilibrium problems Forceful or projectile vomiting Posturing Paralysis or disability on one side of the body Seizures Deteriorating vital signs

Battle’s sign Indication of fracture of middle cranial fossa of the skull, and may suggest underlying brain trauma. It appears as a result of  extravasation of blood along the path of the posterior auricular artery

Raccoon eyes Raccoon eyes may be bilateral or unilateral If unilateral, it is highly suggestive of basilar skull fracture, with a positive predictive value of 85% Most often associated with fractures of the anterior cranial fossa.

CSF rhinorrhea & otorhea Suggestive of basal skull fracture

Brain Injuries Primary (Direct) Brain Injuries Secondary (Indirect) Injuries

Assessment of TBI ABC Alert Verbal Pain Unresponsive Vital signs GCS : Eye opening, Best motor response and Best verbal response History and mechanism of injury

Primary Brain Injuries It occur at the time of original insult Direct damage done to brain parenchyma and associated with vascular injuries Brain tissue can be lacerated, punctured or bruised by broken bones or foreign bodies Damage is already done Irreversible Damage control (debridement)

Secondary Brain Injury Damage that occurs after the initial insult (ongoing injury processes) Expanding mass lesions, swelling or bleeding quickly overwhelm buffers End result is increased intracranial pressure (ICP) and/or herniation Diagnosis and treatments target minimizing the effects of these indirect insults

Herniation

Herniation types

Secondary Injury Mechanisms Mass effect and subsequent elevated ICP and mechanical shifting leading to herniation Hypoxia Hypotension and inadequate CBF Cellular mechanisms

Intracranial Causes Herniation: displaced brain parenchyma Damage to brain from trauma against the dura itself as well as producing ischemia as well Cerebral Edema: intracellular fluid collection within neurons and interstitial spaces. Intra-cerebral Hematomas

Brain Injuries – Brain Concussion Usually caused by blunt injuries. Injuries patient shows transient alteration in neurologic function Mild injury usually with no detectable brain damage. May have brief loss of consciousness. Headache grogginess and short memory loss are common.

Brain Injuries – Brain Contusion A bruised brain or contusion can occur with closed head injuries. Usually caused by blow that causes the brain to hit inside the skull Unconsciousness or decreased level of consciousness can occur

Brain Injuries – A hematoma Is a collection of blood within tissue. Hematoma inside the cranium is named according to its location: Subdural hematoma: blood collection between brain and dura Epidural hematoma: blood collection between dura and the skull Subarachnoid Hemorrhage: Intracerebral hematoma: blood collection within the brain

Epidural Hematomas Blood between inner table of the skull and the dura Lens shaped hematomas that do not cross suture lines on CT

Subdural Hematomas Blood beneath the dura, overlying the brain and arachnoid, resulting from tears to bridging vessels Crescent shaped density that may run length of skull Very common in the elderly

Subarachnoid Hemorrhage Bleeding beneath the arachnoid membrane on the surface of the brain.

Intracranial Hematoma Focal areas of hemorrhage within the parenchyma

ER Care of Skull Fractures and Brain Injuries Take appropriate body substance isolation precautions. Assume spine injury Monitor conscious patient for changes in breathing Apply rigid collar, immobilize the neck and spine Administer high concentration oxygen Control bleeding Keep patient at rest Talk to conscious patient (emotional support) Dress and bandage open wounds Mange the patient for shock Be prepared for vomiting Transport patient promptly Monitor vital signs every five minutes