Head Trauma Free

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**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
-	Localizes pain	Crying	Interacting	5
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 30^o
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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