acute head injury

1. Management of Acute Traumatic
Head Injury
Dr. Manoranjitha Kumari MCh

2. Introduction ..

3. Incidence of Head Injury Indian
Scenario....
• 1.5 to 2 million persons are injured
• 1 million succumb to death every year in
India.
Neurol Res. 2002 Jan;24(1):24-8.
Epidemiology of traumatic brain injuries: Indian scenario.
Gururaj G1

4. Causes ..
Alcohol involvement-10-15%

5. Mechanism of injury

8. Types of head injury

9. DAI

10. • Management ...

11. Evaluation
• ATLS—ABC’s
• History
– loss of consciousness
• Physical exam
– Glasgow Coma Scale
• Radiographic studies
– CT Scan

12. GCS

13. Classifying based on GCS

15. Guidelines..

18. Radiologic examination
• CT scan
– required in ALL cases EXCEPT:
• LOC is brief
AND
• patient can be serially examined
– lesions
• focal--epidural, subdural hematoma,
contusions
• diffuse--diffuse axonal injury
• Plain films
– useful only to detect skull fracture but in the trauma
setting wastes time

19. SDH EDH

21. Indication of surgery
• EDH more than 30 cc clot
• SDH more than 1 cm thickness
• ICH more than 30 CC
• Compound depressed fractures
• Any deterioration of GCS by 2, from the time
of admission even with lesser volume of clot
• Increased intra cranial pressure

28. Hyper acute management in the ICU
• Initial
– Intubation if unresponsive or combative to give
controlled ventilation
– pharmacologic paralysis
• after neurologic exam is completed
– Blood pressure and O2 saturation monitoring
• keep systolic > 90 mm Hg
• 100% O2 saturation

29. ICP monitoring
• Indications
– severe head injury (GCS < 9)
• abnormal head CT
or
• Coma >6 hrs
– Intracranial hematoma requiring evacuation
– Delayed neurologic deterioration from mild to
moderate (GCS>9) to severe (GCS < 8)
– Requirement for prolonged ventilation
– Pulmonary injury, surgery etc.

34. Measures to reduce ICP
• Hyper osmolar therapy
mannitol, 3% NACL, Glycerol
Decompressive craniectomy
Ventilation with paralysing agent

35. ICU management goals
• O2 saturation 100%
• Mean arterial pressure 90-110 mm Hg
• ICP < 20 mm Hg
• Cerebral Perfusion Pressure (CPP=MAP-ICP)
>70 mm Hg

36. CPP

37. Icu adjuncts
• HCT~ 30-33%
• PaCO2= 35±2 mm Hg
• CVP= 8-14 mm Hg
• avoid dextrose IV
• maintain euthermia or mild hypothermia

38. Other issues
• DVT prophylaxis
• Antibiotics
• Anti epileptics
• Nutrition

39. Factors Influencing Prognosis
• Age
– Younger pts have greatest potential for survival and
recovery
– 61-75% mortality if over 65
– 90% mortality in elderly with ICP >20 and coma for more
than 3 days
– 100% mortality if GCS < 5, uni- or bilateral dilated pupils,
and age over 75

40. • survival and recovery not
predictable except in old pts
• Treat presuming recovery

41. Factors Influencing Prognosis
• Hypotension--50% increase in mortality with
single episode of hypotension
• Hypoxia
• Delay in treatment
– prolonged transport
– surgical delay when lateralizing signs present
Potentially controllable!!