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Head Trauma

Prehospital Trauma Life Support

Lesson

8

Copyright 2003, Elsevier Science (USA). All rights reserved.

PROVIDER COURSE

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Objectives

Define primary and secondary brain injury

Discuss how assessment findings suggesttraumatic brain injury

Discuss management for suspected traumatic

brain injury


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Traumatic Brain Injury (TBI)

Commonly occurs in young adults Major contributing cause of trauma deaths Many survivors have permanent disability


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Skull Periosteum

Dura mater } One functional layer Arachnoid membrane

Pia mater (directly attachedto brain surface and notremovable

Vessels insubarachnoid

space

Epidural space

Subdural space

Subarachnoid space

Anatomy


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The Brain


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Pathophysiology

Primary brain injury Secondary brain injury

Systemic causes

Intracranial causes

Can you name some examples of systemic andintracranial causes?


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Secondary Brain Injury

Systemic causes Hypoxia Increased or decreased CO 2

Anemia Hypotension Increased or decreased blood glucose


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Secondary Brain Injury

Intracranial causes Seizures Cerebral edema

Hematomas Increased intracranial hypertension (ICP)


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Intracranial Hypertension

The skull is a rigid, box-like structure Cerebral perfusion pressure

CPP = MAP ICP

If ICP and MAP is unchanged CPP falls Signs of intracranial hypertension

Cushings phenomenon Alterations in ventilatory patterns Abnormal motor posturing


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Primary Survey

Bystanders report a 5-minute loss of consciousness. The child is now awakecomplaining of a headache and hasvomited once.

A - IntactB - NormalC - NormalD - GCS score 14 (E-4, V-4, M-6), PERL

What is a concussion?


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You are called to a local bar where a 22-year-old male has been in a fight. Bystanders statethat your patient was beaten with a pool cue.The scene is safe.


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Primary Survey A - Snoring noisesB - VR slow and shallow; BS equalC - No external hemorrhage, radial pulse fastD - GCS score 6 (E-1, V-1, M-4); pupils R>L, sluggish

E - Multiple hematomas on scalp and face

Vitals: VR, 8; pulse, 110; BP, 150/90

What injuries do these findings suggest?


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Skull Fractures

Simple linear fracture Basilar fracture

Depressed fracture Open skull fracture


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Intracranial Hematoma

Epidural

Subdural Intracerebral

How do these differ?


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Neighbors have called you to the home of an

elderly male who was found down.

A - Snoring noisesB - Cheyne-Stokes breathing

C - Irregular radial pulseD - GCS score 8 (E-2 , V-2, M-4)E - Frontal scalp hematoma

What is the importance of obtaining an AMPLEhistory in this scenario?


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You are called to

the scene of arollover MVC wherea 16-year-oldfemale was ejectedfrom the vehicle.You see the patientlying supine on theground. Her breathing is noisy

and rapid. She hasa large scalplaceration. Youidentify no hazards.


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Primary Survey A - Snoring, gurgling noisesB - VR rapid and shallow; BS decreased

bilaterallyC - Moderate bleeding from scalp; rapid,

bounding carotid pulseD - GCS score 5 (E-1, V-1, M-3)

Vitals: VR, 38; pulse, 124; BP, 80/P


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What life-threatening conditions do you identify?

What could be causing her shock?


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Management

Goals for the TBI patient include preventing and

reversing causes of secondary brain injury


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Airway Management

Why is airway management difficult in the TBIpatient?

Who gets intubated?

What are your options for airway management?


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Ventilatory Support

Avoid hypoxia Supplemental oxygen (SpO 2 95%)

Maintain normal PaCO 2 Assist ventilations, but avoid hyperventilation Use ETCO 2 if available (30-35 mm Hg) Otherwise:

Adults, 10 breaths/min Children, 20 breaths/min Infants, 25 breaths/min


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Circulation

Prevent anemia Control hemorrhage

External

Internal Restore blood volume

Begin fluid resuscitation during transport Maintain systolic BP of at least 90 to 100 mm

Hg


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Disability

Spinal immobilization if indicated Control seizures

Titrate IV benzodiazepines

Sedation may cause hypotension and

ventilatory depression

Copyright 2003, Elsevier Science (USA). All rights reserved.Copyright 2003, Elsevier Science (USA). All rights reserved.

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Intracranial Hypertension

Treat intracranial hypertension Warning signs of possible increasing ICP or

impending herniation:

Decline in GCS score of 2 points or more Development of sluggish or nonreactive pupil Development of hemiplegia or hemiparesis

Cushings phenomenon


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Prehospital Trauma Life Support

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