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Head Trauma

Last Updated: September 27, 2018

Brain Death Determination

1. Coma

  • Noxious stimuli without motor response (except spinal reflexes)

2. Absent Brainstem Reflexes

  • Absent pupillary response to light bilaterally
  • Absent oculocephalic reflex (doll’s eyes)
  • Absent oculovestibular reflex (caloric reflex test bilaterally)
  • Absent corneal reflex
  • Absent facial muscle contraction to noxious stimulus
  • Absent gag and cough reflex

3. Apnea Test

  • Absent respiratory drive despite CO2 challenge (pCO2>60mmHg)

4. Vital signs

  • Core body temperature 36-37oC (normothermia)
  • SBP ≥ 90mmHg
  • PO2 >200mmHg and PaCO2 ~40mmHg à before discontinue ventilator use
  • Verified absence of pharmacologic agent simulating brain death
Changes in Signal Characteristics for Blood on MRI over Time
Time T1 Weighted Image T2 Weighted Image
Acute Gray Black
Subacute White White
Chronic Black Black
Children’s Coma Scale
Consciousness level assessment in children <4 years old
Eye Opening Motor Verbal Score
- Obeys - 6
- Localizes pain Smiles, oriented to sound, follows objects, interacts 5
Crying Interacting
Spontaneous Withdraws to pain Consolable Inappropriate 4
To speech Flexor (decorticate) Inconsistently consolable Moaning 3
To pain Extensor (decerebrate) Inconsolable Restless 2
None None None 1
Classification of Head CT After Trauma
Grading system for brain injury based on cistern compression and midline shift
Diffuse Injury Grade CT Appearance Mortality
I Normal intracranial appearance 9.6%
II Basal cisterns present. Midline shift <5mm. No lesions. 13.5%
III Basal cisterns compressed or absent. Midline shift <5mm. No lesions >25cc. 34%
IV Midline shift >5mm. No lesions >25cc. 56.2%
Classification of Head Injury Severity
Category Qualification (Must meet each criteria in one bullet point)
Minimal
  • GCS = 15 AND no LOC AND no amnesia
Mild
  • GCS = 14
  • GCS = 15 AND either <5 min LOC OR impaired alertness/memory
Moderate
  • GCS = 9-13
  • ≥5 min LOC
  • Focal neurologic deficit
Severe
  • GCS = 5-8
Critical
  • GCS = 3-4
CSF Production, Volume, and Pressure
Normal values for daily CSF production, volume, and pressure
Characteristic Pediatric Adult
Newborn 1-10 years old
Daily Production (ml/d) 25 450-750
Volume (ml) 5 150 (50% intracranial, 50% spinal)
Pressure (cmH2O) 9-12 10 (>15 = abnormal) 7-15 (>18 = abnormal)
Glasgow Coma Scale
Consciousness level assessment
Eye Opening Motor Verbal Score
- Obeys - 6
- Localizes pain Oriented 5
Spontaneous Withdraws to pain Confused 4
To speech Flexor (decorticate) Inappropriate 3
To pain Extensor (decerebrate) Incomprehensible 2
None None None 1
Management of Acute Increase in Intracranial Pressure
Step Description
1 Check airway
2 Elevate head of the bed to 30o
3

Osmotic therapy with mannitol 1gm/kg IV or 10-20ml of 23.4% saline

  • Skip if hypotensive, volume depleted, serum osmolality >320mOsm/L
4 If resistant / sudden IC-HTN is present → STAT non-contrast head CT
5 Drain 3-5ml of CSF if intraventricular catheter is present
6 Ensure patient is sedated and paralyzed
7 Hyperventilation with bag valve mask (to PaCO2 30-35mmHg)
8 Induced coma with pentobarbital 100mg IV or thiopental 2.5mg/kg IV

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