Traumatic Brain Injury
Topics
Introduction
Anatomy
Basic intracranial physiology
Classification of Head injuries
Assessment in head injury
Indications for CT brain study
Management of Minor/Moderate/Severe Head Injury
CT scan films
EDH vs SDH
Craniotomy vs craniectomy
Prognosis
Discharge
Introduction
Primary goal of treatment for patient with
suspected TBI is to prevent secondary brain
injury
Providing adequate oxygenation and
maintaining blood pressure at a level that is
sufficient to perfuse the brain
Anatomy - Scalp
Anatomy – Skull
Anatomy - Meninges
Anatomy – Dura folds
FALX CEREBRI
FALX CEREBELLI
TENTORIUM CEREBELLI
Anatomy – Ventricular system
Lateral
ventricles
Foramen
of
Monroe
Cerebral
aqueduct
Third
ventricle
Foramen
Fourth of Magendie
ventricle
Foramen
of Luschka
Flow of CSF
Anatomy - Brain
Anatomy - Brainstem
Brainstem:
Midbrain
▪ Midbrain and upper pon contain the reticular activating system
responsible for the state of alertness
Pon
Medulla
▪ Vital cardiorespiratory centers reside in the medulla
▪ A small lesion in the branstem may associated with severe neurologic
deficits
Cerebellum
For coordination and balance
Applied anatomy
Ipsilateral
pupillary
dilatation
+
contralateral
hemiparesis is
the classic
sign of uncal
herniation
Brain Herniation
Supratentorial
Uncal (1)
Central (2)
Cingulate (3)
Transcalvarial (4)
Infratentorial
Upward (5)
Tonsillar (6)
Physiology
Once compensatory
mechanism are
exhausted and there is
an exponential
increase in ICP, brain
perfusion is
compromised
Intracranial Pressure
Elevation of ICP can reduce cerebral
perfusion and cause or exacerbate ischemia
Normal ICP in the resting state ~ 10 mmHg
Pressure greater than 20mmHg poor
outcome
(esp sustained and refractory to treatment)
Monro-Kellie Doctrine
Cerebral Blood Flow
CPP = MAP – ICP
CBF = CPP/CVR
Autoregulation
A compensatory mechanism which permits
fluactuation in the CPP within certain limits without
significantly altering CBF
A drop in CPP produce vasodilation maintain
CBF ; vise versa
Autoregulation fails when the CPP falls below 50
mmHg or rise above 150 mmHg
Factors affecting Cerebral Vasculature
PCO2
PaO2 CPP
Extracellular pH
Metabolic by-product Cerebral Vasoconstriction
Autoregulation
Chemoregulation
Chemoregulation Autoregulation
Cerebral Vasodilatation
PCO2
Extracellular pH
CPP
Metabolic by-product
Cerebral Blood Flow
High BP
Low BP or
High ICP
Autoregulation
The injured brain is unable to perform cerebral autoregulation. As a result
CBF is directly dependent on MAP, resulting in the dashed linear curve
shown above. Thus optimize of MAP is critically important in the
management of severe traumatic brain injury.
Cerebral Protection
Effect should be made to enhance cerebral
perfusion and blood flow by
reducing elevated ICP
maintaining normal intravascular volume
maintaining a normal MAP
restoring normal oxygenation
Normocapnia
Protocol Cerebral Protection for TBI
1. Head up 45O
2. Deep sedation (Patient not coughing during
suctioning and no movement)
3. CPP = 60 – 65 mmHg
4. Aim ICP < 20mmHg
5. Temperature – normothermia
6. CVP 10 -12 mmHg
7. ETCO2 = 35-40mmHg
8. Dextrostix = 6 - 8mmol/L
9. Avoid metabolic acidosis
10. CaO2 = 35- 45mmHg
High Risk Patient
The elderly (risk of falls, cerebral atrophy)
Infants (large head size, compressible skull, risk of
non-accidental injury)
Patients with a bleeding diathesis (e.g. on warfarin)
Chronic alcoholics (at risk of falls and assaults,
cerebral atrophy, coagulopathy due to chronic liver
disease)
Classification of Head Injuries
ATLS 9th edition
Management of Severe Brain Injury
(Primary Survey)
1. Activate the trauma team
2. ABCDE approach
3. Airway
Oxygen 100%
Intubated if GCS < 8
Consider intubating patients with higher GCS if agitated, hypoxic or hypoventilating
Avoid nasopharyngeal airways due to the risk of intracranial passage
Immobilize neck until injury to cervical spine excluded
4. Breathing and ventilation
High flow oxygen 15L/min via a non-rebreather mask
Target PaCO2 35 +/- 2 mmHg (low-normal range)
5. Stop blood loss and support circulation
Treat for shock if required
Target MAP of 70 mmHg to maintain adequate CPP
Management of Severe Brain Injury
(Primary Survey)
6. Disability (neurological evaluation)
Asses level of consciousness (GCS), pupils and motor and sensory function in all limbs
prior to sedation or intubation
Antegrade and retrograde amnesia (its extend correlates with the severity of the injury)
suspect critically raised intracranial pressure if: Cushing’s response (bradycardia,
hypertension, apneas), fixed and dilated pupil(s), hemiparesis
treat suspect critically raised intracranial pressure:
head up 30 degrees, remove neck constrictions, administer mannitol 0.25 to 1 g IV bolus
or 3% hypertonic saline according to local guidelines, urgently liaise with neurosurgery
and consider burrholes if transfer to neurosurgeon likely to take >2 hours.
Treat seizure
7. Exposure and Environmental Control
— maintain T36-37oC; give antipyretics if T>38C
GCS Score
Eye Verbal Motor
6 Obey command
Localise pain
5 Orientated
4 Spontaneous Confuse Withdraw pain
3 To call Inappropriate but Flexion
comprehensible (words)
Incomprehensible
2 To pain (Sounds) Extension
1 Close Mute No movement
Adjunct Primary Survey
Adjuncts to Primary Survey and Resuscitation
— ECG and full non-invasive monitoring including temperature
— Obtain trauma series radiographs as needed (lateral cervical spine XR, chest
XR, pelvic XR)
— Bedside ultrasound to identify other injuries and sources of haemorrhage
(e.g. EFAST)
— Seek and treat coagulopathy
— Orogastric tube insertion if intubated
— Indwelling catheter insertion
Subsequent management
Consider transfer
— Organize early transfer to a neurosurgical unit
Secondary survey
— Head-to-toe examination looking for other injuries
Adjuncts to Secondary Survey
— Organize CT head to define the nature of the traumatic brain injury
Continued post-resuscitation care and monitoring
— Ensure adequate sedation and analgesia
— Avoid colloids and hypotonic solutions
—Neurosurgery to consider ICP monitor insertion
-- FASTHUGS IN BED Please
Definitive care and disposition
Diagnostic procedure – CT brain
Findings of significance on CT:
Scalp swelling
Subgaleal hematoma
Skull # (bone view)
Intracranial hematoma
Contusion
Shift of midline (mass effect)
▪ A shift of 5mm or greater is often indicative of the need for
surgery to evacuate the blood clot or contusion causing the shift
Obliteration of basal cisterns
Indications for CT
(‘Nice’ criteria for CT scan)
Indications for Head CT within 1 hour in adults or children
1. GCS < 13 at any time since injury
2. GCS 13 or 14 at 2 hours post-trauma
3. Focal neurological deficit
4. Suspected open or depressed skull #
5. Signs of basillar skull #
6. Post traumatic seizure
7. More than 1 episode of vomiting
Indications for Head CT within 8 hours in adults or children:
8. Anterograde amnesia of > 30 mins
9. Loss of consciousness with or amnesia puls : (any of the following)
Age > 65
Coagulopathy (history of bleed, clotting defect, warfarin therapy)
10. Dangerous mechanism (pedestrain vs vehicles, occupant ejected from vehicle,
fall from > 1m or 5 stairs)
Management
of Mild TBI
Management of
Moderate TBI
Management of Severe TBI
EDH
SDH
Bilateral intraparenchymal bleed with
perilesional edema
Right intraparenchymal hemorrhage with right to
left midline shift associated with biventricular
hemorrhage
Diffuse Axonal Injury
EDH vs SDH
EDH Aspect SDH
Less common Incidences More common
Biconvex or lenticular Shape Semilunar/biconcave (conform
the contours of the brain)
No Crossing Yes
suture
Due to tear of the middle Mechanism Shearing of small surface or
meningeal artery as the result of # (causes) bridging blood vessels of the
Disruption of a major venous sinus cerebral cortex
Skull #
Arterial origin – profuse bleed Complication More severe brain damage due
rapid deterioration & death to presence of concomittant
Life-threatening emergency parenchymal injury
Craniotomy vs Craniectomy
Craniotomy: surgical opening of a portion of the skull
to gain access to the intracranial structures and
replacement of the bone flap
There are many types of craniotomies, which are named
according to the area of skull to be removed. Typically the
bone flap is replaced.
If the bone flap is not replaced, the procedure is
called a craniectomy
craniectomy: surgical removal of a portion of the skull
For EDH decompressive craniectomy
Indicators of a bad prognosis
Old age
Decerebrate rigidity
Extensor spasm
Prolonged coma
Increased BP
Decreased PaO2
Temperature > 39 oC
60% of patient with loss of consciousness > 1
month will survive 3-25 years but required daily
nursing care
Discharge
Patient admitted for minor head injury who are fully alert can safely be
discharged even if there is a simple skull #
Advise for patient
Rest at home for at least 1 week
Inform regarding post-concussion syndrome
▪ Parenchymal lesion has slower recovery
▪ Headache, dizziness, mental deficits, slowness of thought, poor concentration, communication problem,
inability to work, poor performance at school and difficulty with self care
ask someone to stay with you and keep within easy reach of a telephone and medical help for the
first 48 hours after the injury
have plenty of rest and avoid stressful situations
don't drink alcohol or take recreational drugs
don't take sleeping pills, sedatives or tranquillisers (unless they're prescribed by your doctor)
take paracetamol if you have a mild headache, but avoid non-steroidal anti-inflammatory drug
(NSAIDs), such as ibuprofen and aspirin, unless advised or prescribed by a doctor
don't play contact sport, such as football or rugby, for at least three weeks without talking to your
doctor
don't return to work, college or school until you've completely recovered and feel ready
don't drive a car, motorbike or bicycle or operate machinery until you've completely recovered (2-4
weeks PT)
A 67 year old man tripped down some steps at a pub and hit his head. He is
brought to the ED by ambulance. He is GCS 10 (E2V3M5), with PERL and no focal
neurological deficits. He has a hematoma on his left temporal region.
Which patients are at highest risk of morbidity and mortality from traumatic brain injury?
How is the severity of traumatic brain injury classified on initial assessment?
What is the difference between primary and secondary brain injury?
What is the Monro-Kellie doctrine and what are the implications for the management of traumatic brain
injury?
What is cerebral perfusion pressure and how does raised intracranial pressure impair blood flow to the brain?
How is the concept of cerebral autoregulation relevant to traumatic brain injury?
What are the common indications for a head CT in traumatic brain injury?
Anatomically, what are the different types of traumatic brain injury?
Describe your overall approach to the management of a patient with severe traumatic brain injury
Reference
ATLS Student Course Manual 9th edition
Lifeinthefastlane
http://lifeinthefastlane.com/trauma-traumatic-bra
in-injury/
Neurology and neurosurgery illustrated
Burkitt’s Essential Surgery 4th edition
http://www.nhs.uk/Conditions/Head-injury-
minor/Pages/Treatment.aspx
Thank you
When to intubate the patient?
GCS ≤ 8
PaO2 < 70mmHg or PaCO2 > 45mmHg
Spontaneous hyperventilation (PaCO2<
26mmHg)
Respiratory irregularity
Deteriorating level of consciousness
Bilateral # mandible
Bleeding into mouth (skull base #)
Seizures
Hounsfield Unit
