Brain and Craniofacial Trauma

Lt. Colonel Brenda Sowards, RN

Head Trauma

• 50-99% of moderate head trauma victims have permanent injury.

• Motor Vehicle Crashes are primary cause.

• Falls for elderly and children

• High velocity missiles/blast injuries

• 30% have at least one significant concurrent injury.

Pathophysiology

• Primary brain injury

• Direct Trauma

• Involves bleeding, tearing, shearing, neuron damage

• Secondary brain injury

• Hypoxia, hypercapnea, hypotension, hyperglycemia, hypoglycemia, increased intracranial pressure, swelling, seizures

Head Injuries

• Scalp Lacerations

• Skull Fractures

• Concussions

• Contusions

• Intracranial Bleeding

• Cerebral Edema

Scalp Lacerations

• Rich blood supply

• Can cause hypovolemic shock

• Often deeper brain injury has occurred

• Direct pressure to control bleeding

• Do not apply excessive pressure

• Complete neurological exam

Skull Fractures

• Significant force has been applied to the skull.

• Injuries from bullets, blasts,blunt force, other penetrating objects.

• Risk of infection, if open skull fracture.

• X-ray or CT

• Deformity

• Skull fragments

Skull Fractures

• Raccoon Eyes• Indicates maxilofacial fractures around eyes

• Ecchymosis (Black eyes)

• Visual Acuity

• Eye bulges out (Exopthalmos)

• Eye sinks in (Enopthalmos)

Skull Fractures

• Battle’s sign• Associated with basilar skull fracture

• Blood accumulation behind one or both ears (forms bruising 12-24 hours later)

• Hemotympanum

• CSF drainage from ears or nose (never pack)

• Check extraocular movements

Concussion

• Temporary loss of brain function

• May result in loss of consciousness

• Confusion

• Amnesia

• Dizzyness

• Weakness

Concussion

• Coup- same side injury

• Contra-coup-opposite side injury

• Contusions may occur as the brain scrapes the inside of the skull• Bleeding, permanent injury, swelling, amnesia,

unconsciousness

Intracranial Bleeding

• Epidural Hematoma

• Subdural Hematoma

• Intracerebral Hemorrhage

Epidural Hematoma

• Occurs above the dura lining

• Occurs below the skull

• Most often arterial bleeding

• Develops rapidly

• Rapid deterioration of neurologic functions

• Lucid phase

Subdural Hematomas

• Occurs beneath the dura

• Occurs outside the brain

• Usually venous in nature

• Develops slowly

• Progressive loss of neurological function

• Patients may not remember blunt trauma

Intracranial Hemorrhage

• Bleeding occurs within the brain itself

• Caused by tearing, shearing of blood vessels

• Spinal Taps contraindicated due to increased swelling

Cerebral Edema

• Most common complication of head injury

• Aggravated by low oxygen levels

• Seizures increase oxygen consumption

• Causes increased intracranial pressure

• Normal ICP 10-15 mm

Cerebral Ischemia

• Headache

• Nausea and vomiting

• Amnesia for events before or after injury

• Altered level of consciousness

• Restlessness, drowsiness

• Changes in speech

• Loss of judgement

Intracranial Pressure

• Cerebral Perfusion Pressure (CPP)

• Mean Arterial Pressure (MAP)

• Autoregulation

Autoregulation

• An increase in mean arterial pressure leads to vasoconstriction of cerebral vessels.

• A decrease in mean arterial pressure leads to vasodilation of cerebral vessels.

• Hypoxia and Hypovolemia are the main causes of secondary brain injury.

Intracranial Pressure

• Cerebral perfusion must be adequate to prevent secondary brain injury.

• Prevention starts by treating shock.• Keep mean arterial pressure between 60 and 180

mm Hg.• One episode of hypotension significantly increases

morbidity and mortality. • Position patient to facilitate venous drainage.

Monro-Kellie Doctrine

Glasgow Coma ScaleEYE OPENING

• Spontaneous

• To Voice

• To Pain

• None

4

3

2

1

Glasgow Coma Scale

VERBAL RESPONSE

• Oriented

• Confused

• Inappropriate Words

• Incomprehensible Words

• None

5

4

3

2

1

Glasgow Coma ScaleMOTOR RESPONSE

• Obeys Commands

• Localizes Pain

• Withdraws (pain)

• Flexion (pain)

• Extension (pain)

• None

6

5 4

3

2

1

Glasgow Coma Scale

• Predicts mortality

• Measures level of consciousness

• Motor component most sensitive subset

• Indicates improvement or deterioration

• GCS of 9-15 indicates mild to moderate injury

• GCS of 3-8 indicates severe head injury

Pupil Assessment

• Size

• Light Response

• Equal

• Compare

Posturing

• Decorticate- hands turn inward toward

• Decerebrate-hands turn outward

• Happens prior to herniation syndrome.

Treatment

• Prevent secondary injury

• Airway-oxygen and intubation if GCS < 8

• Treat shock-normotensive

• Hyperventilation is only indicated if patient shows signs of impending herniation

• Control bleeding from other injuries

• RAPID transport if possible

Treatment

• Continual assessment-pupils & GCS

• Treat seizures-increased oxygen consumption of the brain

• Watch for respiratory pattern changes-may indicate your patient is worsening.

Management of Suspected Traumatic Brain Injury

P e rfo rm E nd o tra ch e a l In tu b a tion

Y e s

C o n tin u e T ra nsp o rt

N O

C o n tin u e T ra nsp o rt

S ed a tionP a ra lys is

O sm o th era pyC o n tro lle d H yp erve n tila t ion

Y e s

S ig n s o f inc re ase d IC P ?

C h e ck b lo o d g lu co se le ve l

T re a t S e izu res

V o lu m e resu scita t ion

In it ia te tra n sp o rt

C o n tro l E x te rna l H em o rrh a ge

A ss is t V e n tila t io ns

A p p ly o xyg enM a in ta in S p O 2

N o

G la sgo w C o m a S ca le< 8

S u spe c te d T B I

QUESTIONS ?