Head Trauma

dr. Andy Wijaya, SpEM

Emergency Medicine Specialist
Head of Accident & Emergency Department
Husada General Hospital
• Brain  fixed volume (the skull)
• Type of trauma : Intracranial Haemorrhage,
Basillar skull fracture, skull fracture
• Trauma  Bleeding n swelling  ↑ICP 
brain herniation (commonly uncal herniation)
• Goals :
– Support oxygenation + Blood pressure (prevent
secondary brain injury)
– Identify head injury (intervention or observation )
• Cerebral Perfusion Pressure :
CPP = MAP – ICP
– Ideal CPP > 60 mmHg
– Ideal MAP > 80 mmHg
– Ideal ICP < 15 mmHg
• Symptoms depend on severity of injury
– Mild focal headache
– Loss of conciousness
– Amnesia (retro or antero)
– vomiting
• Examination
– Level of severity
– Calculate GCS
– Review vital sign, High ICP may cause Cushing
reflex ( hypertension, bradycardia and irregular
respiration)
– Pupillary exam :
• A single fixed + dilated pupil  sign of ipsilateral uncal
herniaton ( in awake patient  ocular trauma )
• Bilateral fixed + dilated pupils  complete uncal
herniation, poor brain perfusion or stimulant use)
– Motor exam  to assess focal neurologic deficits
or posturing :
• Decorticate posturing
• Decerebrate posturing
– Brainstem exam (Resp. pattern, papillary size and
eye movement)
• Oculocephalic response : “doll’s eyes”  indicates
intact brainstem function in comatose patient
• Oculovestibular response : 30 mL ice cold saline into
ear; nystagmus  intact brainstem function
• Diagnosis
– Head CT w/o contrast
• Anyone with a change in mental state
• Elderly patient or have coagulopathy
• Vomiting or persistent headache
– Children < 2 y.o head CT if :
• Focal neurology abnormality
• Altered mental state
• Any scalp trauma
(laceration/ecchymosis/contusion/abrasion)
• Vomiting
• Treatment
– Aggressive management  prevent secondary
brain injury
– Placed in critical care area
– Ensure adequate oxygenation and ventilation
– Intubate if GCS ≤ 8 or presence of intracranial
injury by CT
– Head elevated 30⁰
– Infusion with Normal saline
– Aggressive treat hypotension to maintain SBP ≥ 90
mmHg,
– Seizure prophylaxis with phenytoin (prevent early
post traumatic seizure)
– Antiemetics for nausea/vomiting
– Analgetic, avoid NSAID
– Antibiotics if any open wound
– If evidence for herniation :
• Hyperventilate to PCO2 of 30 – 35 mmHg
• Manitol 0.25 – 1 g/KgBW i.v bolus (osmotic diuretis),
contraindicated for renal impairment patient
• Emergency burr hole (by neuro surgeon)
– Consult neuro surgeon division
– Admitted to Intensive care ward or Cito operation
Intracranial Haemorhage
 Epidural Hematome
• Associated with skull
fracture
• Middle meningea artery
• Rapid expansion
• CT show : biconvex
opacity
• Usually temporo/
temporoparietal area
• Present lucid interval due
to expanding hematoma
• Surgical emergency
 Subdural Hematome
• Caused by tearing of bridging
veins
• Commonly in elderly n alcoholics
 brain atrophy n ↑intracranial
space
• May be associated with minor or
no known trauma
• Crescent shaped hematome on
CT :
– Bright  acute
– Dark  chronic (> 14 days)
• Surgical intervention
(Decompresion) for acute < 24 h
or sub acute < 2 weeks, or
associated with AMS or
significant midline shift > 5mm
 Traumatic subarachnoid
Haemorrhage
• Cause by disruption of
subarachnoid vessels
• Most common ICH in
moderate to severe TBI
• Typically, photophobia
and/or meningeal signs
 Basillar Skull Fracture
• Most commonly throught the petrous portion of
temporal bone
• Symptoms / Exam :
– Vertigo
– Hearing difficulties / hearing loss
– CSF otorrhea and/or rhinorrhea
– Mastoid ecchymosis (battle’s sign)
– Periorbital ecchymosis (raccoon eyes
– Hemotympanum
– 7th nerve palsy
• Treatment :
– Analgetics, antiemetic
– Antibiotics
– Avoid to insert NGT or airway device (NPA)
• Complication :
– Meningitis
– meningoencephalitis
 Skull fracture
• Type of fracture
– Linier fracture
• Rarely clinically significant in and of itself
• Concern is for underlying brain injury, vascular
bleeding, thrombosis, or suture diastasis
• May present with pain and hematoma
• Diagnosis by palpation, plain radiograph and CT scan
(maybe missed on axial CT scan)
• Linear fractures rarely require repair and may be
discharged if otherwise asymptomatic
– Comminuted Fracture
• Fracture in many fragments
• Open skull fractures (overlying skin broken) require
antibiotics
• Debridemant in operation room
– Depressed Fracture
• A comminuted fracture with inward displacement
• If depression is greater than the thickness of adjacent
inner table, may require surgical elevation
• Depressed fractures may present with skull crepitus
• Diagnosis by palpation, plain radiograph and CT scan
• Depressed skull fractures may require surgical elevation
if depression greater than adjacent inner skull table
thickness
 Special Consideraton
Diffuse axonal injury (shear injury)
• Definition
– Diffuse axonal injury causing severe depressed level of consciousness
out of proportion to radiographic findings
• Etiology
– White and grey matter have different densities and therefore tears
one from another with sudden acceleration and deceleration or
rotation motor vehicle accident (MVA), shaken baby syndrome
• Symptoms and signs
– Spectrum of illness related to degree of injury and mechanism ranging
from brief loss of consciousness to persistent vegetative state
– Complex ongoing biochemical cascade may cause delayed injury and
worsening symptoms and signs
• Diagnosis
– Clinical and unfortunately, often a histologic diagnosis
– MRI is superior to CT, but both modalities may be nondiagnostic