Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 6 n Head Trauma
Head injuries are among the most common
types of trauma encountered in emergency
departments (EDs). Many patients with severe
brain injuries die before reaching a hospital; in fact,
nearly 90% of prehospital trauma-related deaths
involve brain injury. Approximately 75% of patients
with brain injuries who receive medical attention can
be categorized as having mild injuries, 15% as moderate,
and 10% as severe. Most recent United States data
estimate 1,700,000 traumatic brain injuries (TBIs)
occur annually, including 275,000 hospitalizations
and 52,000 deaths.
TBI survivors are often left with neuropsychological
impairments that result in disabilities affecting work
and social activity. Every year, an estimated 80,000 to
90,000 people in the United States experience long-term
disability from brain injury. In one average European
country (Denmark), approximately 300 individuals
per million inhabitants suffer moderate to severe head
injuries annually, and more than one-third of these
individuals require brain injury rehabilitation. Given
these statistics, it is clear that even a small reduction
in the mortality and morbidity resulting from brain
injury can have a major impact on public health.
The primary goal of treatment for patients with
suspected TBI is to prevent secondary brain injury. The
most important ways to limit secondary brain damage
and thereby improve a patient’s outcome are to ensure
adequate oxygenation and maintain blood pressure
at a level that is sufficient to perfuse the brain. After
managing the ABCDEs, patients who are determined
by clinical examination to have head trauma and
require care at a trauma center should be transferred
without delay. If neurosurgical capabilities exist, it
is critical to identify any mass lesion that requires
surgical evacuation, and this objective is best achieved
by rapidly obtaining a computed tomographic (CT)
scan of the head. CT scanning should not delay patient
transfer to a trauma center that is capable of immediate
and definitive neurosurgical intervention.
Triage for a patient with brain injury depends on how
severe the injury is and what facilities are available
within a particular community. For facilities without
neurosurgical coverage, ensure that pre-arranged
transfer agreements with higher-level care facilities
are in place. Consult with a neurosurgeon early in the
course of treatment. n BOX 6-1 lists key information
to communicate when consulting a neurosurgeon
about a patient with TBI.
A review of cranial anatomy includes the scalp, skull,
meninges, brain, ventricular system, and intracranial
compartments (n FIGURE 6-1).
Scalp
Because of the scalp’s generous blood supply, scalp
lacerations can result in major blood loss, hemorrhagic
shock, and even death. Patients who are
subject to long transport times are at particular risk
for these complications.
Skull
Anatomy Review
The base of the skull is irregular, and its surface can
contribute to injury as the brain moves within the
skull during the acceleration and deceleration that
occurs during the traumatic event. The anterior fossa
houses the frontal lobes, the middle fossa houses the
temporal lobes, and the posterior fossa contains the
lower brainstem and cerebellum.
Meninges
The meninges cover the brain and consist of three
layers: the dura mater, arachnoid mater, and pia
mater (n FIGURE 6-2). The dura mater is a tough,
box 6-1 neurosurgical consultation for patients with tbi
When consulting a neurosurgeon about a patient with TBI, communicate the following information:
• Patient age
• Mechanism and time of injury
• Patient’s respiratory and cardiovascular status
(particularly blood pressure and oxygen saturation)
• Results of the neurological examination, including the
GCS score (particularly the motor response), pupil size,
and reaction to light
• Presence of any focal neurological deficits
• Presence of suspected abnormal neuromuscular status
• Presence and type of associated injuries
• Results of diagnostic studies, particularly CT scan
(if available)
• Treatment of hypotension or hypoxia
• Use of anticoagulants
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