1. Head Trauma

2. 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

3. Superior view of the skull

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

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

6. 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.

7. Anatomy of skull

8. Injuries to the scalp

9. Scalp injuries

10. Scalp injuries

11. 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

12. 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

13. 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

14. 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.

15. CSF rhinorrhea & otorhea
Suggestive of basal skull fracture

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

17. 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

18. 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)

19. 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

20. Herniation

21. Herniation types

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

23. 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

24. 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.

25. 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

26. 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

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

28. 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

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

30. Intracranial Hematoma
Focal areas of hemorrhage within the parenchyma

31. 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