Management of

Patients with
Neurologic Trauma
Lj Conejar
Nor Safinah
Head injury is a broad term encompassing any trauma to
the head, with traumatic brain injury (TBI) specifically
referring to damage resulting from external force,
significantly impacting daily life and requiring treatment.
While a head injury doesn't necessarily equate to a brain
injury, TBIs present a significant public health

Epidemiology: According to the Centers for Disease

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Control and Prevention (CDC), the United States witnesses
an annual estimate of 2.9 million emergency department
(ED) visits due to head injuries, with the majority
classified as mild TBIs. TBIs contribute to approximately
30% of all injury-related deaths, resulting in 56,800
fatalities, 288,000 hospitalizations, and 80,000 to 90,000
cases of long-term disability. Falls, motor vehicle crashes,
object strikes, and assaults are the primary causes, with
higher TBI rates for males across all age groups.
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Prevalence and Economic Impact: Children up to
4 years old, adolescents aged 15 to 19, and adults
aged 65 and older are most susceptible to TBIs.
Currently, an estimated 5.3 million people in the
U.S. live with TBI-related disabilities, generating an
annual economic impact of approximately $76.5

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billion due to medical expenses and lost
productivity.
Prevention: The most effective approach to head
injury is prevention. Implementing safety measures,
especially in high-risk groups, can significantly
reduce the incidence of TBIs. Education, public
awareness campaigns, and the promotion of safety
practices in various settings play a crucial role in
preventing traumatic brain injuries.
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Pathophysiology
• Traumatic brain injury (TBI) manifests in two
distinctive forms: primary injury, occurring instantly
upon head/brain contact, and secondary injury,

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evolving over subsequent hours and days.
• Primary injuries include extracranial focal injuries
like contusions, lacerations, external hematomas, and
skull fractures, alongside possible focal brain injuries
from sudden brain movement within the cranial vault
(e.g., subdural hematomas, concussion, diffuse axonal
injury). Implementation of prevention strategies
presents the greatest opportunity for decreasing TBI.

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Pathophysiology
• Secondary injury, a critical focus of early
TBI management, emerges due to inadequate
delivery of glucose and oxygen to cells.
Contributors include intracranial pathologic

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processes (intracranial hemorrhage, cerebral
edema, intracranial hypertension, seizures,
vasospasm) and systemic effects (hypotension,
hyperthermia, hypoxia, hypercarbia, infection,
electrolyte imbalances, anemia). These factors
contribute to a complex interplay of
biochemical, metabolic, and inflammatory
changes that further compromise the injured
brain. 5
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 Pathophysiology
• Monro–Kellie hypothesis elucidates the dynamic
equilibrium of cranial contents, emphasizing the
closed system nature of the cranial vault. If one
component (brain, blood, CSF) increases in
volume, at least one of the others must decrease,

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or intracranial pressure (ICP) will rise. Bleeding
or swelling within the skull elevates volume,
causing increased ICP. If this pressure surges, it
can lead to brain displacement against rigid skull
structures, restricting blood flow, diminishing
oxygen delivery, and impairing waste removal.
The ensuing anoxia and improper metabolism
result in ischemia, infarction, irreversible brain
damage, and ultimately, brain death. 7
Scalp Injury
Classification:
Nature: Isolated scalp trauma is generally considered a minor injury.
Bleeding Characteristics: Due to poor constriction of numerous blood vessels, scalp injuries tend to bleed
profusely.
Types of Scalp Injuries:
Abrasions: Also known as brush wounds.

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Contusions: Bruising of the scalp tissue.
Lacerations: Tears or cuts in the scalp.
Subgaleal Hematoma: Accumulation of blood beneath the layers of scalp tissue.
Emergency Consideration:
Avulsion: A large tearing away of the scalp is considered a true emergency and may be life-threatening.
Diagnosis:
Methods: Diagnosis relies on a thorough physical examination, inspection, and palpation.
Infection Risk and Management:
Portal of Entry: Scalp wounds pose potential portals for organisms causing intracranial infections. 8

Irrigation: Prior to suturing, the affected area is irrigated to remove foreign material, minimizing infection
.
Scalp Injury
Diagnosis:
Methods: Diagnosis relies on a thorough physical
examination, inspection, and palpation.
Infection Risk and Management:

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Portal of Entry: Scalp wounds pose potential portals
for organisms causing intracranial infections.
Irrigation: Prior to suturing, the affected area is
irrigated to remove foreign material, minimizing
infection risk.
Subgaleal Hematomas:
Characteristics: These hematomas, beneath scalp
layers, typically reabsorb without requiring specific
treatment. 9
Skull
. Fractures:
A skull fracture is a disruption in the continuity of the skull resulting from forceful trauma.

Occurrence and Brain Damage:

May occur with or without concomitant damage to the brain.

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Types:
Linear Fracture: Simple break in the bone's continuity.
Comminuted Fracture: Splintered or multiple fracture lines.
Depressed Fracture: Bones forcefully displaced downward, varying from a slight
depression to embedding within brain tissue.

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Skull
. Fractures:
• Basal Skull Fracture:
• A specific type of fracture occurring at the base of the skull.
• Open and Closed Fractures:
• Open Fracture: Indicates a scalp laceration or tear in the

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dura, often associated with external objects like bullets or ice
picks.
• Closed Fracture: Dura remains intact despite the fracture
• Location:
• Frontal, Temporal, and Basal Skull Fractures:
Classifications based on the fracture's location.

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 Clinical Manifestations
• Symptoms:
• Localized Pain: Persistent, localized pain often
suggests the presence of a skull fracture.
• Swelling: Presence or absence of swelling

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depends on the location of the fracture within the
cranial vault.
• Anatomic Location and Symptoms:
• Cranial Vault Fractures:
• Swelling: May or may not produce swelling in the
region of the fracture.
• Pain: Persistent localized pain is a common indicator. 13
 Clinical Manifestations
• Base of the Skull Fractures:
• Paranasal Sinus or Middle Ear Involvement:
Fractures may traverse the paranasal sinus of the
frontal bone or the middle ear located in the temporal
bone.

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• Hemorrhage: Frequently produces hemorrhage from
the nose, pharynx, or ears, with blood potentially
appearing under the conjunctiva.
• Ecchymosis (Battle Sign): Bruising over the mastoid
region may be observed.
• Cerebrospinal fluid Leakage: Suspected when
cerebrospinal fluid (CSF) escapes from the ears (CSF
otorrhea) and nose (CSF rhinorrhea). 14
 Clinical Manifestations

• CSF Drainage: Serious concern

due to the risk of meningeal
infection if organisms access

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cranial contents through a tear in
the dura.

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 Assessment and Diagnostic
Findings
• Computed Tomography (CT) Scan:
• Purpose: Utilized for diagnosing skull fractures.
• Ease of Diagnosis: The ease of diagnosing a skull fracture
via CT scan depends on the site of the fracture.

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• Associated Brain Injury: If a fracture is identified, there
arises a concern about associated brain injury.
• Magnetic Resonance Imaging (MRI):
• Resolution and Clarity: Offers better resolution and clearer
images of the injured area compared to CT scans.
• Complementary Role: While CT scans are effective for initial
diagnosis, an MRI scan becomes valuable for detailed
assessment, especially in cases of identified skull fractures
that raise concerns about associated brain injuries
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•.
Medical Management
Non depressed Skull Fractures:
Surgical Treatment: Generally not required for nondepressed fractures.
Observation: Close monitoring of the patient is essential.
Location: Patients may be observed in the hospital, but if no underlying brain
injury is present, they may be allowed to return home.

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Instructions: If discharged, specific instructions are provided to the family,
especially concerning later discussions on concussions.
Depressed Skull Fractures:
Surgical Intervention: Usually necessitates surgery within 24 hours of injury.
Procedure: Surgery involves elevation of the skull and debridement.
Fracture Types: Skull fractures can be open, compound, closed, or simple.
Associated Injuries: Concurrent injuries may include scalp laceration, Dural
tears, and brain injury directly below the fracture due to compression and
lacerations by bony fragments. 17
Brain Injury
Critical Considerations in Head Injuries: Focus on Brain Damage
Primary Concern: Brain Injury:
Severity of Impact: Regardless of the perceived severity of head injury, the primary
consideration is the potential for brain damage.

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Hidden Consequences: Even seemingly minor injuries can lead to significant brain
damage due to obstructed blood flow and reduced tissue perfusion.
Limited Brain Nutrient Storage:
Oxygen and Glucose: The brain lacks significant storage capacity for oxygen and
glucose.
Continuous Blood Supply: Cerebral cells depend on an uninterrupted blood supply
for essential nutrients.
Consequences: Interruption of blood supply, even for a few minutes, can lead to
irreversible brain damage and cell death.
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Brain Injury
Critical Considerations in Head Injuries: Focus on Brain Damage
Types of Traumatic Brain Injuries:
Closed (Blunt) Traumatic Brain Injury:
Definition: Occurs when the head accelerates, rapidly decelerates, or collides

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with an object without an opening through the skull and dura.
Mechanism: Brain tissue is damaged internally due to the force of impact.
Open (Penetrating) Traumatic Brain Injury:
Definition: Involves an object penetrating the skull, entering the brain, and
causing damage to soft brain tissue.
Mechanism: Alternatively, severe blunt trauma may open the scalp, skull, and
dura, exposing the brain to potential damage

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Types of Brain Injury
Cerebral Contusion:
Definition: Cerebral contusion occurs when the brain is bruised and
damaged in a specific area due to severe acceleration-deceleration
forces or blunt trauma.
Mechanism: Impact of the brain against the skull leads to the

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formation of a contusion.
Clinical Manifestations:
Factors Influencing Manifestations: Clinical signs depend on the
size, location, and extent of surrounding cerebral edema.
Common Locations: Contusions often occur in the anterior portions
of the frontal and temporal lobes, around the sylvian fissure, and at
the orbital areas; less commonly in parietal and occipital areas.
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Types of Brain Injury
Characteristics of Contusions:
Loss of Consciousness: Contusions can lead to loss of consciousness
accompanied by stupor and confusion.
Temporal Lobe Pronounced Effects: Effects of injury, including
hemorrhage and edema, peak after 18 to 36 hours, with temporal lobe

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contusions showing the most pronounced impact.
Secondary Effects: Hemorrhage and edema can result in increased
intracranial pressure (ICP) and potential herniation syndromes.
Management Approach:
Medical Management: Patients are primarily managed medically,
focusing on interventions to prevent additional insults.
Deep Contusions and Arousal: Deep contusions, often associated
with hemorrhage and destruction of reticular activating fibers, can 21

alter arousal levels.

Types of Brain Injury
Intracranial Hemorrhage:
Intracranial hematomas, categorized as epidural, subdural, or intracerebral, are critical consequences of
traumatic head injuries, each demanding distinctive management strategies. Major symptoms may delay
until a hematoma causes brain distortion and increased intracranial pressure (ICP).
Epidural Hematoma (EDH): Occurs in the extradural space due to skull fracture, often involving middle
meningeal artery.

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EDH symptoms include brief loss of consciousness, lucid interval, and subsequent deterioration.
Considered an emergency, necessitating burr holes or craniotomy for clot removal and bleeding control.

Etiology and Incidence: Resulting from blood accumulation above the dura, typically from a middle
meningeal artery rupture due to skull fracture.
Clinical Features: EDHs may present with a brief loss of consciousness, succeeded by a lucid interval
before deteriorating into coma.

Emergency Situation: Immediate intervention is vital due to the potential for rapid neurologic
deterioration. Burr holes or craniotomy is performed to reduce intracranial pressure (ICP), remove the clot, 22
and control bleeding.
Types of Brain Injury

Subdural Hematoma (SDH): Collection between dura and brain, often traumatic or
due to coagulopathies.
Acute SDH:
Cause: Often trauma-related, with symptoms including altered consciousness, pupillary changes, and

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hemiparesis.
Management: Rapid transport to the hospital for emergent craniotomy to evacuate the subdural clot
and monitor ICP. Mortality rates are high due to associated brain damage.

Chronic SDH: Develops from minor head injuries, more common in older adults with brain
atrophy.

Occurrence: Common in older adults due to brain atrophy, with an insidious onset and symptoms
developing weeks to months after minor head injuries.
Features: Symptoms may mimic stroke, and surgical evaluation for clot evacuation is considered,
often through burr holes or craniotomy. Symptoms are diverse, including headache, focal signs, mental
changes, and seizures.
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Types of Brain Injury
Intracerebral Hemorrhage: Bleeding into brain parenchyma,
commonly seen in head injuries or nontraumatic causes.

Causes: Traumatic incidents, systemic hypertension, aneurysm rupture, vascular

anomalies, tumors, bleeding disorders, and anticoagulant therapy complications.

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Presentation: Symptoms may develop insidiously with neurologic deficits and
headaches.
Management: Supportive care, ICP control, and meticulous administration of
fluids and antihypertensive medications. Surgical intervention may be
challenging based on the location and extent of bleeding.

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Types of Brain Injury
Concussion
Concussion, accounting for 80% of 1.7 million yearly TBIs in the U.S.,
manifests as a temporary neurologic dysfunction without detectable
brain structural damage.

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Typically caused : blunt trauma, acceleration–deceleration forces, or
blasts, it can induce diverse symptoms based on the affected brain
region. The duration of mental status abnormalities guides grading, and
discharge occurs upon the patient's return to baseline .

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Types of Brain Injury
Vigilant monitoring for red flags like decreased LOC, seizures, or
abnormal pupil response is crucial, as even seemingly complete recovery
may mask long-term sequelae.

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Repeated concussions, common in contact sports, pose a risk of chronic
traumatic encephalopathy, resembling Alzheimer's disease, with
noticeable cerebral atrophy, particularly in the temporal lobe.

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Types of Brain Injury
Diffuse Axonal Injury (DAI)

DAI arises from widespread shearing and rotational forces,

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causing extensive damage throughout the brain, affecting axons
in the cerebral hemispheres, corpus callosum, and brain stem.
Unlike focal lesions, DAI presents as a diffuse injury without a
distinct focal lesion. It is linked with prolonged traumatic coma
and carries a graver prognosis compared to focal lesions.

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Types of Brain Injury
Diffuse Axonal Injury (DAI)

Diagnosis: Clinical signs and CT/MRI

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Recovery: Dependent on the severity of axonal injury.

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Medical Management
Assessment and Diagnosis:
• Initial physical and neurologic examinations are key for evaluating the
extent of head injury.
• CT and MRI scans are primary tools for neuroimaging, providing insights
into brain structure.
• Positron emission tomographyInsert(PET) is employed
or Drag and in some trauma centers
Drop your Image
to assess brain function (Schweitzer et al., 2019).
Cervical Spine Injury Protocol:
• Any head injury patient is presumed to have a cervical spine injury until
proven otherwise.
• Transportation on a board with head and neck alignment.
• Application of a cervical collar until cervical spine x-rays confirm the
absence of cervical spinal cord injury (SCI).
Medical Management
Treatment of Increased Intracranial
ICP Increase Management:
• Swelling or blood accumulation in the damaged brain leads to increased intracranial
pressure (ICP).
• Aggressive treatment is required to address ICP elevation, emphasizing the relationship
between ICP and cerebral perfusion pressure (CPP) (refer to Chapter 61).
• Initial management focuses on preventing secondary
Insert or Drag and injury and ensuring sufficient
Drop your Image
cerebral oxygenation (Sacco & Delibert, 2018).
Surgical Interventions:
• Surgery becomes necessary for various aspects of traumatic brain injuries:
• Evacuation of blood clots.
• Débridement and elevation of depressed skull fractures.
• Suturing severe scalp lacerations.
• Close monitoring of ICP is crucial during surgery.
• Increased ICP is managed by maintaining adequate oxygenation, elevating the head of
the bed, and ensuring normal blood volume (McCafferty et al., 2018).
Medical Management
Treatment of Increased Intracranial

ICP Monitoring and CSF Drainage:

• Devices for ICP monitoring or CSF drainage can be inserted during surgery
or at the bedside with aseptic technique.
Intensive Care Unit (ICU)Insert
Care:
or Drag and Drop your Image

• Post-surgery, the patient is cared for in the ICU, ensuring access to expert
nursing care and immediate medical treatment.
Medical Management
Supportive Measures
• Ventilatory Support and Airway Protection:
• Comatose patients are intubated and mechanically ventilated to ensure sufficient oxygenation and protect the airway.
• Seizure Prevention:
• Anticonvulsant agents are administered to prevent seizures, which can cause secondary brain damage.
• Benzodiazepines, particularly lorazepam and midazolam, are commonly used for sedation without affecting cerebral
blood flow or ICP.
• Propofol, an ultrashort-acting sedative–hypnotic,
Insert or is preferred
Drag dueyour
and Drop to its rapid onset, short elimination half-life, and
Image
titratability to desired clinical effects (Hickey & Strayer, 2020).
• Fluid and Electrolyte Maintenance:
• Fluid and electrolyte balance is carefully maintained.
• Nutritional Support:
• Nutritional support is provided to ensure the patient receives essential nutrients.
• Pain and Anxiety Management:
• Pain and anxiety are managed as part of the overall treatment plan.
• Nasogastric Tube Insertion:
• A nasogastric tube may be inserted due to reduced gastric motility and reverse peristalsis associated with head injury,
reducing the risk of regurgitation and aspiration in the initial
 :
Brain Death
•Cardinal Signs of Brain Death:
•Three cardinal signs of brain death during clinical examination include coma, absence of brain stem reflexes, and
apnea.
•Adjunctive tests, such as cerebral blood flow studies, EEG, transcranial Doppler, and brain stem auditory-evoked
potential, may be used to confirm brain death.
•Family Support and Decision-Making:
•Assists the family in theThe health care team provides information to the family.
• decision-making process regarding end-of-life care.
Thank
You