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

2. 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

3. 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

4. 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

5. 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

6. GCS

7. Indication for imaging

8. 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

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

10. 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

11. 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

12. Types of TBI

13. 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

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

15. 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

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

17. 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

18. 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

19. Management of TBI

20. 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

21. head elevation > 30 degree
sedation and analgesia
paralysis
maintain PaCO 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

22. Thank You