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CME

Head Trauma - Emergency Management

General Information

General InformationGeneral Information

Background

  • Head trauma is a general term that encompasses trauma to the scalp, skull, and brain
  • The most important consequence of head trauma is traumatic brain injury (TBI), any acquired brain injury caused by blunt or penetrating trauma
    • Type and extent of injury can vary greatly and are classified as
      • Mild (Glasgow Coma Score [GCS] = 13-15)
      • Moderate (GCS = 9-12)
      • Severe (GCS = 3-8)

Anatomy

  • There are 4 bones in the skull: the frontal, temporal, parietal, and occipital bones
  • Underlying the skull are multiple layers of meninges and spaces between the bone and brain, proceeding from external to internal
    • Epidural space: contains middle meningeal artery
    • Dura mater: contains venous sinuses
    • Subdural space: encloses the most delicate portion of bridging veins
    • Arachnoid mater: follows the sulci and gyri of the brain
    • Subarachnoid space: contains the cerebrospinal fluid (CSF)
    • Pia mater: thin layer that adheres closely to the brain parenchyma
  • The brain can be described in terms of the cerebrum, cerebellum, and brainstem structures
    • Cerebrum are divided into lobes which include the frontal, parietal, temporal, and occipital
    • Brainstem structures include the midbrain, pons, and medulla oblongata
    • Cerebellum is located posteriorly in the skull

Etiology

  • Traumatic brain injury (TBI) is the leading cause of injury-related death and acquired disability1,2
  • Blunt trauma accounts for the majority of head injuries1,2
  • Falls are the most common mechanism1,2
  • Greatest mortality (75%-80%) is from motor vehicle collisions (MVC)1,2
  • Consider nonaccidental trauma in pediatric patients
  • Primary injury results from the inciting traumatic event1,2
    • Soft tissues injuries, fractures, brain contusions, hemorrhages (epidural, subdural, subarachnoid), diffuse axonal injuries, and herniation
    • Cranial nerves may be injured from stretching or contusion (CN II, III, VI, VII most at risk)
  • Secondary injury results from ischemia to traumatized brain and cellular damage that progresses over hours to days1,2
    • The goal care for TBI patients is to minimize secondary injury
    • Inadequate volume resuscitation contributes to hypo-perfusion injury, especially in patients with concomitant multisystem trauma
    • Hypoglycemia, hypoxia, and other metabolic factors such as hyperthermia can also contribute to secondary injury
    • Brain edema, untreated intracranial bleeding, and elevated intracranial pressure (ICP) can cause severe damage

Epidemiology

  • Brain injury occurs in 60% of major trauma and 70% of multisystem injury1
  • Traumatic brain injury (TBI) is more common in children than adults1
  • Males are affected twice as often as females1
  • 95% do not require neurosurgical intervention1
  • Children have an overall lower mortality and better prognosis than adults; however, infants and young children have a higher mortality1

References

References

General References Used

  1. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010
  2. Werner C, Engelhard K. Pathophysiology of traumatic brain injury. Br J Anaesth. 2007 Jul;99(1):4-9
  3. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70
  4. Greenberg, M. Neurosurgical exam in trauma. In: Handbook of Neurosurgery. 7th ed. New York, NY: Thieme Medical Publishers; 2010
  5. Dayan PS, Holmes JF, Schutzman S, et al.; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014 Aug;64(2):153-62
  6. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100-5
  7. Sandsmark DK. Clinical Outcomes after Traumatic Brain Injury. Curr Neurol Neurosci Rep. 2016 Jun;16(6):52
  8. Wakai A, McCabe A, Roberts I, Schierhout G. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev. 2013 Aug 5;8:CD001049
  9. Marincowitz C, Allgar V, Townend W. CT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study. Emerg Med J. 2016 Aug;33(8):538-42
  10. Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011 Jul;71(1):245-51
  11. Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014 Aug;64(2):145-52
  12. Wilberger JE Jr, Deeb Z, Rothfus W. Magnetic resonance imaging in cases of severe head injury. Neurosurgery. 1987 Apr;20(4):571-6
  13. Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010 Feb;68(2):471-7
  14. Greenberg, M. Neuroanesthesia. In: Handbook of Neurosurgery. 7th ed. New York, NY: Thieme Medical Publishers; 2010
  15. Debenham S, Sabit B, Saluja RS, et al. A critical look at phenytoin use for early post-traumatic seizure prophylaxis. Can J Neurol Sci. 2011 Nov;38(6):896-901
  16. Jones KE, Puccio AM, Harshman KJ, et al. Levetiracetam versus phenytoin for seizure prophylaxis in severe traumatic brain injury. Neurosurg Focus. 2008 Oct;25(4):E3
  17. Szaflarski JP, Sangha KS, Lindsell CJ, Shutter LA. Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care. 2010 Apr;12(2):165-72
  18. Moulton RJ, Pitts LH. Head injury and intracranial hypertension. In: Hall JB, Schmidt GA, Wood LD, eds. Principles of Critical Care. 3rd ed. New York, NY: McGraw-Hill; 2005
  19. Marmarou A, Saad A, Aygok G, Rigsbee M. Contribution of raised ICP and hypotension to CPP reduction in severe brain injury: correlation to outcome. Acta Neurochir Suppl. 2005;95:277-80
  20. Kamel H, Navi BB, Nakagawa K, Hemphill JC 3rd, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011 Mar;39(3):554-9
  21. Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg. 2012 Jan;116(1):210-21
  22. Mortimer DS, Jancik J. Administering hypertonic saline to patients with severe traumatic brain injury. J Neurosci Nurs. 2006 Jun;38(3):142-6
  23. King NS. A systematic review of age and gender factors in prolonged post-concussion symptoms after mild head injury. Brain Inj. 2014;28(13-14):1639-45

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T906221, Head Trauma - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T906221. Registration and login required.

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