12/05/2026
๐๐ซ๐๐ฎ๐ฆ๐๐ญ๐ข๐ ๐๐ซ๐๐ข๐ง ๐๐ง๐ฃ๐ฎ๐ซ๐ฒ
Head injury is a major entity, often encountered in acute care, the head being the most frequently injured part of the body in trauma patients. This patients are usually unconscious and are likely to require support to the airway and breathing, continuous monitoring and skilled management. Management and prognosis of head injury depend mainly on the extent and pathophysiologic type of brain injury.
Effect of injury to the brain:
โข Primary impact damage is due to acceleration/ deceleration forces on to the skull content.
โข Secondary damage results from hemorrhage and edema. Intracerebral and subdural bleeding can occur. Hematoma within the skull causes increased ICP and even brain shift.
โข Fracture of skull:
o Depressed fracture
o Compound fracture: infection
o Fracture base of skull: bleeding into the nasopharynx, aspiration
o Fracture nasal bones: rhinorrhea, infection
โข Extradural hematoma:
โข Cerebral edema:
o Increased ICP
o Increasing coma
o Fixed dialated pupil
o Apnea
o Respiratory failure
Classification:
1. Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull.
2. Head injuries can be closed or open.
A closed (non-missile) head injury is where the Dura mater remains intact. The skull can be fractured, but not necessarily. A penetrating head injury occurs when an object pierces the skull and breaches the Dura mater.
3. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.
4. Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a countercoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).
5. Mild, Moderate and Severe
Management of Traumatic Brain Injury
A. Immediate assessment and treatment:
The โfirst lineโ assessment (including physical examination) and treatment of any head-injured patient are closely inter-related and include the following:
โข Secure (or maintain) the patientโs airway.
โข Optimise oxygenation and ventilation.
โข Initiate haemodynamic resuscitation and fluid administration.
โข Identify both intracranial and extracranial injuries.
โข Prioritisation of injuries (see management algorithm). Collate information about the mechanism of the injury and relevant past medical history.
โข Continue to (re)assess level of consciousness.
1.Airway and breathing:
โข Hypoxia is associated with higher mortality and increased morbidity following TBI. Hypercapnia is not commonly detected but may contribute to vascular engorgement and induce increases of intracranial pressure.
โข The following manoeuvres should be performed without delay.
o Give high-flow oxygen (by face mask) to all patients with traumatic brain injury regardless of its severity.
o Presuming the presence of appropriate skills, intubate and ventilate patients with any impairment of airway reflexes or with abnormal pupillary response to light.
o Adopt strategies to minimise any immediate hypotension after intubation and ventilation.
o Avoid and/or treat aspiration.
o Check that arterial saturation is >95% except in patients with impaired lung mechanics or profound hypoxia in whom lower SpO2 values (90%) may be preferable to the potentially injurious effect of recruitment and high PEEP levels.
o Avoid hyperventilation in the early phase of the injury. Early use of end-tidal CO2 is strongly encouraged and pCO2 should be kept between 30โ35 mmHg (4โ4.5 kPa) in normotensive patients. Avoid hypercapnia.
2.Circulation:
โข Hypovolaemia and hypotension are also associated with more mortality and morbidity following TBI. Once you have dealt with the airway and breathing you should rapidly turn your attention to the patientโs circulation.
โข Insert at least two large bore peripheral intravenous cannulae.
โข If hypotension occurs: first check for extracranial injuries.
โข In patients without penetrating injuries and not suspected of having internal bleeding, establish a normal arterial blood pressure for patients age to obtain an adequate cerebral perfusion pressure. For adults consider a systolic pressure >110 mmHg and for older patients >130 mmHg.
โข In patients with TBI and active bleeding accept a systolic pressure of 90 mmHg and rapidly transfer the patients to the closest trauma centre.
โข Use intravenous isotonic solutions (e.g. Ringerโs-Solution, NaCl 0.9%) and colloids for volume resuscitation.
โข Hypertonic saline has been used in the resuscitation of injured patients with TBI. Its efficacy in regard to survival and neurological outcome in TBI has yet to be proved.
โข Theoretically, in patients with suspected increased intracranial pressure and with hypotension due to bleeding, hypertonic saline should be appropriate.
โข In patients with clinical signs of transtentorial herniation high-dose mannitol (1โ2 gr/kg) or hypertonic saline are potentially useful to reverse herniation.
โข The routine use of colloids for patients with TBI is controversial. Results from the SAFE study showed a significantly higher mortality rate (24.6% vs 16%) in those patients with TBI who were volume resuscitated with albumin vs saline. For this reason, many practitioners avoid the use of colloids in these patients.
โข Give vasopressor agents if adequate volume replacement fails to produce an adequate systolic blood pressure within minutes. In the context of TBI no one vasopressor has been shown to be superior to the other. Isolated intracranial injury in the adult does not cause hypotension, except in extremely severe patients, usually with bilaterally dilated unreactive pupils
โข In patients with penetrating injuries and in those with internal bleeding, increase systolic pressure with catecholamine to no more than 90 mmHg.
โข Requirement for catecholamine during transfer is not uncommon and requires infusion via syringe pumps.
โข Use catecholamine if hypotension appears to be due to sedation and ventilation.
3.Monitoring:
โข Optimal resuscitation is facilitated by establishing accurate and reliable monitoring rapidly.
โข Basic monitoring is indicated in all patients with significant head injury while more advanced monitoring is appropriate in selected instances.
i.Basic monitoring
โข Basic monitoring of patients with isolated head injuries should be initiated, where possible, at the site of the accident and include:
o 3-lead-ECG (all patients).
o Pulse rate and arterial blood pressure, non-invasive (all patients).
o Pulse oximetry (all patients).
o Capnography (ventilated patients). You will find of value the section on the relationship between PaCO2 and Pet CO2 in the following reference.
o Capnography is strongly suggested in the extrahospital setting where hypoventilation or inadvertent therapeutic hyperventilation is common.
ii.Neurological monitoring
โข Neurological monitoring may be initiated either in the emergency room or in the operating room (ICP-device) and after admission to the ICU
o EEG,
o Evoked potentials,
o Transcranial Doppler,
o Jugular bulb catheterisation.
iii.Further monitoring
โข After initial resuscitation, involving airway, breathing, and circulation, additional practical procedures include:
o Central venous catheter (moderate/severe injuries; multiple trauma)
o Arterial catheter (moderate/severe injuries; multiple trauma)
o Nasogastric tube (or orogastric tube in presence of bad facial injuries)
4.Patient investigation
i.Laboratory:
During the course of resuscitation, blood should be drawn for laboratory analyses. The sooner this is done the more valuable are the results in assessing the patientโs subsequent progress. After admission to the emergency room the following laboratory values are obtained in all patients:
โข Haemoglobin (haematocrit), leukocytes, platelets
โข Sodium, potassium, blood glucose
โข Coagulation parameters
โข Blood type
โข Blood urea, creatinine and electrolytes
โข Liver enzymes
โข Pregnancy test (where appropriate).
โข If available, more complex analysis of coagulation physiopathology should be indicated especially in patients with known or suspected history of anticoagulants or antiplatelets use and in patients with multiple injuries
โข Patients with moderate or severe head injuries also require:
o Cross-matching of at least four units of blood
o Arterial blood gases.
ii.Radiological:
Initial investigations should include the following: In emergency room
โข X-rays, Chest, pelvis
โข Abdominal โFASTโ scanning Isolated TBI
โข CT scan of the head
โข CT scan of cervical spine (C1 to T1) TBI and multiple injuries
โข CT scan thorax , abdomen, pelvis
โข Reconstruction of thoracic and lumbar spine
โข Angio-CT, arterial, venous and delayed phase
โข In the last few years, the improvement of time acquisition for CT scanning, suggests that whole body CT scan should be considered more in multiple injured patients as the first radiologic examination. In TBI patients, this approach will be less time consuming than screening X-rays of chest and pelvis done in ER. The immediate use of whole body CT should be associated with a continuation of resuscitation care by means of the transfer of damage control strategies into the CT room.
B. Further and more detailed physical examination (secondary survey):
Upon completion of initial resuscitation and stabilisation of the patientโs vital signs, you should undertake a careful head-to-toe examination. Inspect and feel the entire scalp. Wounds may be hidden by blood-clotted hair and fractures may be palpable. Look for
โข Periorbital haematomas, bruising behind the ear (Battleโs sign) as shown in this illustration; cerebrospinal fluid (CSF) rhinorrhoea or otorrhoea may indicate basal skull fractures.
โข Open injuries of the cranial vault with obvious CSF leakage or cerebral debris including gunshot wounds and stabbing.
โข Foreign bodies (glass or metal splinters).
โข Maxillofacial injuries and injuries to the eyes.
โข Observe the spontaneous breathing pattern of the patient. Before intubation abnormal respiratory patterns may indicate severe neurological damage. Diaphragmatic breathing, for example, may indicate an injury to the lower cervical spinal cord.
โข In males, priapism may also indicate spinal cord injury.
โข Assume all patients with head injuries have fractures of the spine (especially cervical spine) and treat them accordingly until such fractures have been ruled out radiographically. Road-traffic accidents and falls from great heights are associated with the highest risk of associated spinal injuries.
Neurological examination:
The key aims of neurological assessment in the early stages of TBI are to determine the level of consciousness and to note the presence or absence of focal or lateralising neurological signs. In carrying out a neurological assessment:
โข Determine the level of consciousness according to the Glasgow Coma Scale
โข Examine the pupils for size, symmetry, and reaction to light. The response of the pupils to light is dependent on intact afferent (optic nerve) and efferent (oculomotor nerve) function transmitting the light impulse from the retina to the midbrain and hence the pupillary musculature. Pupillary abnormalities are very common in patients in traumatic coma. Assess the size and shape of each pupil both separately and compared to the other. Assess the response of the pupils to light, both directly and indirectly.
โข Examine the most meaningful brain-stem reflexes (corneal reflex, abnormal eye movements, cough and gag reflexes).
โข Examine motor responses (arms and legs). In conscious patients, begin with commands such as โLift up your right armโ. In unconscious patients noxious stimuli such as pinching the ear lobe or cheek, or pressing firmly on the fingernail bed are used to elicit a response. All four limbs should be checked independently to detect focal deficits.
โข Major findings from carrying out this mini-neurological examination may include:
o Hemiparesis caused, in most cases, by an intracranial injury.
o Monoparesis of one limb, which may either be the result of a direct limb injury or the consequence of peripheral nerve damage (e.g. monoparesis of one arm caused by an injury to the brachial plexus).
o Paraparesis is usually the result of a spinal cord injury.
o Check for respiratory abnormalities.
o Consider, in restless agitated patients, that patients with frontal lobe contusions may be without motor deficit.
โข Regular observation and careful documentation is critical to the detection of neurological changes. A relevant, neurological deterioration is considered a decline of GCS of two points, or an evolution of CT scan, or a new abnormality in pupil reactivity to light.
โข Repeated GCS measurement is indicated even when the initial GCS value is high. In such case a decline of GCS is a useful guide for further CT and clinical decisionmaking e.g. as an indication for surgery or ICP monitoring. Conversely, patients presenting with low GCS values, abnormal pupil reactivity and with neurosurgical emergencies do not get the same benefit from further neurological examination as intubation and ventilation is implemented as soon as possible and, in such cases, repeated GCS evaluation may well conflict with appropriate care.
C. Assessment of severe head injury:
Inevitably, a proportion of patients have severe brain injury as a result of primary or secondary damage. These patients are amongst those normally transferred to a general ICU or a neuro surgical ICU as a function of local hospital organisation and resources. Patients with moderate brain injury may also require an intensive care setting for a decline in neurological status and airway defence reflexes or to monitor ICP if there is a risk of evolution of a mass lesion.
i.Neurological monitoring:
Some measurements are considered routine in specialised centres and units. Others are more experimental, more complex and their value in the management of individual patients is still uncertain.
Standard measurements:
โข Neurological status (GCS, pupils, motor signs, brain-stem reflexes)
โข ICP
โข Cerebral perfusion pressure.
Advanced measurements:
โข Brain tissue PO2
โข Thermo dilution CBF measurement
โข Jugular bulb oximetry
โข Transcranial Doppler
โข Evoked potentials
โข Continuous EEG
โข Microdialysis
โข Cortical microelectrodes.
ii.ICP monitoring:
A good grasp of three physiological concepts will aid in your management of patients with TBI. To refresh:
โข Intracranial volume is a constant in adults. An increase in any of the component volumes (blood/CSF/brain/pathological mass) must result in a decrease in one or more of the others (Monro-Kellie doctrine).
โข The relationship between intracranial volume and ICP is exponential.
โข Cerebral perfusion pressure (CPP) is defined as the difference between mean arterial pressure and mean ICP (i.e. CPP = MABP - ICP).
iii.The place of advanced monitoring techniques in head injury:
a.Global measurement:
โข ICP: Measurement of ICP remains the cornerstone of monitoring in the patient with traumatic brain injury. When linked to data on MAP it provides a measurement of CPP, which is a rough estimate of CBF. Global CBF seems to be dependent on CPP predominantly in the first hours post injury. Conversely, in patients who survive and stabilise in ICU, CPP and global CBF are not correlated, probably as the result of preserved autoregulation and maintenance of CPP within autoregulatory range.
โข SjO2: Newer adjuncts to ICP monitoring include jugular venous saturation monitoring (SjO2) which allows the clinician to monitor cerebral oxygen extraction for any given CPP.
โข Brain tissue oxygen levels (ptiO2) and thermal diffusion regional cerebral blood flow (TD-rCBF) measurements: A valuable alternative to SjO2 is the meausurement of ptiO2 and TD-rCBF. These monitoring devices are extremely focal but once placed in apparently normal brain, they seem to be sensitive to the same variables that affect SjO2 โ a recognised global monitoring modality.
b.Focal measurement:
โข ptiO2 and TD-rCBF: The apparent limitation of ptiO2 and rCBF (their regionality) is conversely the reason that they can be placed in perilesional oedematous regions.
D. General intensive care โ with particular reference to TBI patients:
i.Sedation:
โข Sedation is usually achieved with an infusion of either propofol or midazolam together with an opioid (usually morphine or alfentanil).
โข Thiopental may be beneficial in the presence of severely compromised cerebral blood flow and metabolism, or status epilepticus.
โข Neuromuscular blockade is frequently used in addition to sedative drugs.
ii.Central nervous system:
โข Avoid oversedation
โข Agitation after withdrawal of sedation
iii.Respiratory system:
โข Patient positioning
o Appropriate positioning may reduce the frequency of pulmonary complications and silent (micro-) aspiration.
o The patient should be inclined head-up at 30ยฐ, and should be nursed if possible alternatively on their back, right and left sides.
โข Ventilation
o Mechanical lung ventilation is particularly important in patients suffering from multiple trauma, especially with the combination of head and chest injuries, to ensure optimal oxygenation in the face of pulmonary contusion.
o This is normally achieved by the use of IPPV and may involve the use of small amounts of positive end-expiratory pressure (PEEP).
o The main benefits of mechanical ventilation are the prevention of hypercapnia and the provision of adequate cerebral oxygenation.
โข Early and ultra-early tracheostomy
o Early tracheostomy (4โ6 days post injury), or ultra-early tracheostomy (1โ3 days post injury) have been claimed as advantageous in reducing the use and duration of sedation, duration of mechanical ventilation and in preventing pulmonary and laryngeal complications.
o It may also accelerate safe discharge from ICU to a lower level of care and so enhance early physical rehabilitation.
iv.Gastrointestinal system โ nutrition and stress ulceration:
โข Feeding is important to reduce catabolic effects and maintain immunological competence.
โข Nutrition via the enteral route is more physiological, less expensive and is associated with fewer complications than parenteral nutrition.
โข There is a minor increased risk of reflux and potential for aspiration. However, gastric pH is higher (more neutralised) by enteral nutrition and the airway has a significant degree of protection against aspiration due to the cuffed tube.
โข Enteral nutrition should be started shortly after admission with the intention of reaching full nutritional intake by day 3 in ICU.
โข Fluid restriction may be appropriate, and if large amounts of fluid have been given during initial resuscitation, a gentle drug-induced diuresis with furosemide to create an overall negative fluid balance (or at least to prevent a positive balance) may be appropriate.
โข The use of mannitol tends to be reserved for the emergency treatment of raised ICP rather than the treatment of simple fluid overload.
v.Detailed Neurological Assessment:
โข The Glasgow Coma Scale, which is based upon eye opening, and verbal and motor responses, is used in non-sedated patients.
โข Brain function may also be assessed by use of the electroencephalogram (or a processed EEG monitor such as the cerebral function analyzing monitor [CFAM]), transcranial Doppler and near-infrared spectroscopy.
vi.ICP Monitoring
โข The ICP is monitored using a transducer inserted either extradurally, subdurally or into the brain parenchyma. This may be undertaken in the ICU or in the operating theatre.
โข ICP often increases in response to stimulation, physiotherapy, tracheal suction, etc., but should return to the pre-stimulation value within 5โ10 min.
โข Frequent and prolonged increases in ICP demonstrate a low cerebral compliance and the need for further sedation and ventilation.
โข If weaning from mechanical ventilation is started and the ICP increases and remains elevated, the patient should be re-sedated and the lungs ventilated for a further 24-h period.
โข It is beneficial to nurse head-injured patients in a 15ยฐ head-up tilt to assist in control of ICP, provided that coexisting conditions permit.
(Ref: TBI Update + Stoilting)
