Advanced Trauma Life Support ATLS Student Course Manual 2018

CLASSIFICATION OF HEAD INJURIES 109
a normal CPP may help improve CBF; however,
CPP does not equate with or ensure adequate CBF.
Once compensatory mechanisms are exhausted
and ICP increases exponentially, brain perfusion
is compromised.
upper/lower asymmetry, be sure to use the best motor
response to calculate the score, because it is the most
reliable predictor of outcome. However, the actual
responses on both sides of the body, face, arm, and leg
must still be recorded.
Classification of head
injuries
Head injuries are classified in several ways. For practical
purposes, the severity of injury and morphology are
used as classifications in this chapter (n TABLE 6-1).
(Also see Classifications of Brain Injury on MyATLS
mobile app.)
Severity of Injury
The Glasgow Coma Scale (GCS) score is used as an
objective clinical measure of the severity of brain injury
(n TABLE 6-2). (Also see Glasgow Coma Scale tool on
MyATLS mobile app.) A GCS score of 8 or less has
become the generally accepted definition of coma or
severe brain injury. Patients with a brain injury who
have a GCS score of 9 to 12 are categorized as having
“moderate injury,” and individuals with a GCS score
of 13 to 15 are designated as having “mild injury.” In
assessing the GCS score, when there is right/left or
Morphology
Head trauma may include skull fractures and intracranial
lesions, such as contusions, hematomas, diffuse
injuries, and resultant swelling (edema/hyperemia).
Skull Fractures
Skull fractures can occur in the cranial vault or skull base.
They may be linear or stellate as well as open or closed.
Basilar skull fractures usually require CT scanning
with bone-window settings for identification. Clinical
signs of a basilar skull fracture include periorbital
ecchymosis (raccoon eyes), retroauricular ecchymosis
(Battle’s sign), CSF leakage from the nose (rhinorrhea)
or ear (otorrhea), and dysfunction of cranial nerves VII
and VIII (facial paralysis and hearing loss), which may
occur immediately or a few days after initial injury. The
presence of these signs should increase the index of
suspicion and help identify basilar skull fractures. Some
fractures traverse the carotid canals and can damage
the carotid arteries (dissection, pseudoaneurysm, or
table 6-1 classifications of traumatic brain injury
Severity
• Mild
• Moderate
• Severe
• GCS Score 13–15
• GCS Score 9–12
• GCS Score 3–8
Morphology • Skull fractures • Vault • Linear vs. stellate
• Depressed/nondepressed
• Basilar
• With/without CSF leak
• With/without seventh nerve palsy
• Intracranial lesions • Focal • Epidural
• Subdural
• Intracerebral
• Diffuse
• Concussion
• Multiple contusions
• Hypoxic/ischemic injury
• Axonal injury
Source: Adapted with permission from Valadka AB, Narayan RK. Emergency room management of the head-injured patient. In: Narayan RK, Wilberger
JE, Povlishock JT, eds. Neurotrauma. New York, NY: McGraw-Hill, 1996:120.
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