1. MANAGEMENT
ASSESSMENT
OF HEAD INJURY

2. ACUTE MANAGEMENT
Resuscitation
BTLS/ATLS APLS
ASSESSMENT

3. A IRWAY
B REATHING
C IRCULATION

4. A IR WAY

5. Maintain SPO2 > 90%
Maintain PaO2 > 60mmHg

6. When do you intubate?

7. Indication for intubation
GCS ≤ 8
Loss of protective laryngeal
Unable to maintain airway reflexes
Unstable facial bone #
Bleeding into mouth
Seizures
Ventilatory insufficiency Spontaneous hyperventilation
Irregular respiration

8. B REATHING

9. Maintain PCO2 35-40mmHg
Obtain CXR ASAP
Check ABG

10. C IRCULATION

11. Prevent hypotension
Aim SBP> 90mmHg
Resuscitation with isotonic cystalloid
Inotropes (adrenalin) if needed

12. Mortality rate
2.5 x
Hypotension
2x + Hypoxia
Hypotension
Normal
Traumatic Coma Data Bank study

13. NEUROLOGICAL
ASSESSMENT

15. Opens their eyes when you say their
name, and speaks to you in words that
make no sense. When you apply
pressure on their nail bed, they move
their arm away.
10 - M4 V3 E3

16. Moves hand towards head when you apply
pressure above the eye socket. They are
disoriented but able to form sentences. They
open their eyes in response to speech.
12 - M5 V4 E3

17. Spontaneously looks around. When you
speak to the patient, they can tell you who
they are, where they are and why, and the
date, and obey simple commands.
15 - M6 V5 E4

18. Adult, can obey simple commands and opens
their eyes when they hear you speak. They
can talk to you in sentences and seem a little
confused and unsure of where they are.
13 - M6 V4 E3

19. Indications For Referral to
HOSPITAL

20. Indications for Referral to Hospital
•GCS<15 at initial assessment for two hours and refer if GCS score
remains<15 after this time)
•ƒ post-traumatic seizure (generalised or focal)
•ƒ focal neurological signs
•ƒ signs of a skull fracture (including cerebrospinal fluid from nose or
ears,haemotympanum, boggy haematoma, post auricular or periorbital
bruising)
•ƒ loss of consciousness
•ƒ severe and persistent headache
•ƒ repeated vomiting (two or more occasions)
•ƒ post-traumatic amnesia >5 minutes
•ƒ retrograde amnesia >30 minutes
•ƒ high risk mechanism of injury (road traffic accident, significant fall)
•ƒ coagulopathy, whether drug-induced or otherwise.

21. Indications For
CT-SCAN

22. Indications for CT-Scan
•eye opening only to pain or not conversing (GCS 12/15 or less)
•ƒ confusion or drowsiness (GCS 13/15 or 14/15) followed by failure to
improve within
•at most one hour of clinical observation or within two hours of injury
(whether or
•not intoxication from drugs or alcohol is a possible contributory factor)
•ƒ base of skull or depressed skull fracture and/or suspected penetrating
injuries
•ƒ a deteriorating level of consciousness or new focal neurological signs
•ƒ full consciousness (GCS 15/15) with no fracture but other features, eg
- severe and persistent headache
- two distinct episodes of vomiting
•ƒ a history of coagulopathy (eg warfarin use) and loss of consciousness,
amnesia or
•any neurological feature.

23. When to discuss with a
Neurosurgeon

24. A patient with a head injury should be
discussed with a neurosurgeon:
•When a CT scan in a general hospital shows a recent
intracranial lesion
•ƒ When a patient fulfils the criteria for CT scanning but
facilities are unavailable
•ƒ When the patient has clinical features that suggest
that specialist neuroscience assessment, monitoring, or
management are appropriate, irrespective of the result of
any CT scan.

25. Head Injury
Closed Penetrating
head injury head injury
Mild Moderate-
severe
Cerebral
concussion

26. What is cerebral concussion?
“physiologic injury to the
brain without any evidence
of structural alteration”

28. “Many of these patients require only minimal
observation after they are assessed carefully, and
many do not require radiographic evaluation.”

29. Management
• Keep NBM
• IV Drip all NS
• GCS chart
• Vital sign monitoring
• Analgesia
• Manage other injuries

30. CPP = MAP – ICP
CPP = cerebral perfusion pressure
>70mmHg in adult
> 60mmHg in children

31. CPP = MAP – ICP
MAP= Mean Arterial Pressure
= DP + 1/3 (SP - DP)

32. CPP = MAP – ICP
ICP= Intracranial pressure
Range 5mmHg (infant) to 15mmHg (adult)

33. CEREBRAL BLOOD FLOW
50 150
SYSTOLIC BLOOD PRESSURE
Autoregulation is lost in trauma, resulting in a linear
relationship of BP to cerebral blood flow

34. Monroe Kellie Doctrine Principle
• Cranium is a closed space
• Changes in one of the intracranial components
will result in compensatory alteration in the
others
Brain 80% Brain 70%
Expanding haematoma
CSF Blood CSF Bloo
10% 10% 5% 5%

35. Cerebral
Resuscitation

36. Aim - Prevention of secondary brain insults
• Avoid hypotension & maintain CPP
• Avoid hypoxia
• Decrease ICP
• Decrease brain metabolism

37. Circulatory Support: Maintain Cerebral Perfusion
Pressure (50-70mmHg)
6
5
Number of 4 Good
Hypotensive Moderate
Episodes 3
Severe
2 Vegetative
1
Dead
0
Outcome
Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

38. Use of
hyperventilation

39. Use of hyperventilation
• Hyperventilation ↓ PCO2
• ↓ PCO2 will cause cerebral vasoconstriction and
reduce cerebral blood flow → ↓ ICP
• Harmful effect of reduce blood flow and causing
hypoxia to the brain tissue
• Current guideline
– Prophylaxis hyperventilation not recommended
– Only used in the management of very acute
elevation of ICP
– Moderate (PCO2 30-35mmHg) and transient (<30min)

40. Reducing
Intracranial Pressure

41. Decrease ICP
• Promote venous return
• Decrease metabolism of brain
• Decrease brain volume
– Decrease brain blood volume
– Decrease CSF volume
– Remove space occupying lesion
• Open the skull to give more room

42. 30o

43. Promote venous return
• Keep neck mid-line and elevate head of be to 30⁰
• Early clearance of cervical collar
Dicarlo in ALL-NET Pediatric Critical Care Textbook
www.med.ub.es/All-Net/english/neuropage/protect/icp-tx-3.htm

44. Decrease metabolism of brain
• Sedation
– Propofol + morphine
– Barbiturates – not recommended unless refractory
raised ICP despite maximal medical & surgical
intervention
• Paralysis
– Stops muscle activity
• Anticonvulsants
– Indicated to prevent early PTS (within 7 days)
– No benefit for prevention of late PTS
– No evidence suggest early PTS a/w poor outcome

45. • Hypotermia
– Reduce metabolic rate
– Keep normothermia or mild hypothermia
• T 35-37⁰C
• Treat pain and agitation
– consider lignocaine
– Consider pre-medication for nursing activities
– Allow family contact

46. Decrease brain volume
• Drain CSF – ventricular catheter
• Hyperosmolar therapy – reduce oedema
– Mannitol 0.25g-1g/kg body weight (200cc 20% in
20min infusion) effectively reduce ICP
– C/I SBP<90mmHg
– Hypertonic saline – possible better than mannitol,
but no strong evidence regarding dose,
concentration & administration method
– S/E – rebound phenomenon, central pontine
myelinolysis in hypoNa
• Remove blood clot

47. Indication for Surgery
• EDH
– Any GCS, EDH > 30ml
– Conservative with serial CT
• <30ml + <15mm thickness + <5mm MLS + GCS>8 + no
focal deficit
• SDH
– Any GCS, thickness >10mm or MLS >5mm
– In patient GCS <9 + thickness <10mm + MLS
<5mm, surgery if GCS droped ≥ 2 or
asymmetric/fixed pupil or ICP >20mmHg

48. Other surgical interventions
• Skull bone elevation
– Depressed > thickness of cranium
– > 1cm depression
– Wound contamination
• Decompressive craniectomy

49. Other supportive managements
• Infection prophylaxis
– Recommended
• Antibiotic for intubation to prevent pneumonia
• Early tracheostomy
– Not recommended
• Routine change of ventricular catheter/ antibiotic prophylaxis
• DVT prophylaxis
– Mechanical prefered
– Can use LMWH/ Heparin but with risk of clot expansion
• Prevent bed sore

50. • Nutrition
– Should start immediately if no C/I
– Should attain full calories by PTD7
• Glycaemic control
– Tight control 4.5-8.5 mmol/L
– Hyperglycaemia a/w poor outcome
• Rehabilitation

51. Conclusion
• TBI is a major leading cause of death
• Involved high numbers of admission and one
of the highest cost for treatment
• Basic knowledge regarding TBI and initial
assessment and treatment is important before
referral to neurosurgical team to ensure better
outcome of patients
• Keyword – FAST, to prevent secondary brain
insult which is a/w poorer outcome

52. Reference
• The Brain Trauma Foundation. Guidelines for the
management of severe traumatic brain injury.
http://www.braintrauma.org
• The Brain Trauma Foundation. Prehospital Emergency Care
• The Brain Trauma Foundation. Early indicators of Prognosis
in Severe Traumatic Brain Injury.
• The Brain Trauma Foundation. Surgical Management of TBI
Author Group.
• NICE clinical guideline 56. Head injury: triage, assessment,
investigation and early management of head injury in
infants, children and adults. http://www.nice.org.uk/CG56
• Clinical Neuroanatomy for Medical Students , Richard S.
Snell.