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Battlefield Advanced Trauma Life Support J R Army Med Corps 2002; 148: 151-158 J R Army Med Corps: first published as 10.1136/jramc-148-02-10 on 1 June 2002. Downloaded from BATLS Battlefield Advanced Trauma Life Support CHAPTER 8 HEAD INJURIES inside the skull. Because the skull is a rigid box, an increase in the size of the brain, the Aim volume of blood or amount of 0801. On successfully completing this topic cerebrospinal fluid within it, will cause an you will be able to: increase in ICP. Cerebral perfusion refers to • Discuss general management of the the supply of oxygenated blood to the unconscious casualty with a head injury. brain. • Understand the anatomy and • Cerebral perfusion pressure (CPP) pathophysiology of head injury. depends on the blood pressure pushing • Understand than an altered level of blood into the brain and the resistance to consciousness is the hallmark of brain this blood flow from the ICP. If the ICP injury. rises then a higher blood pressure is • Demonstrate the initial assessment and needed to supply blood to the brain. In management of a casualty with a head other words - injury. • Assess the criteria for neurosurgical CPP = MAP - ICP referral in war. Note: MAP (Mean Arterial Pressure)1. Introduction Normal value 70 to 90 mmHg. 0802. Head injury is common: it carries a Normal ICP 10 mmHg high mortality both in peacetime and on the If CPP is less than 50 mmHg, cerebral battlefield. The aim of initial management of hypoxia will follow. a casualty with a head injury is: • Lack of oxygen (hypoxia) makes the brain 1. To prevent secondary brain swell. Raised carbon dioxide levels in the blood causes cerebral blood vessels to injury due to cerebral hypoxia http://militaryhealth.bmj.com/ 2. To identify injuries needing dilate which increases the volume of blood urgent surgery. in the head and further raises ICP.This is why management of Airway and Breathing is essential. 0803. This is done by appropriate • Raised ICP may also be due to obstruction management of: Airway, Breathing, of venous drainage from the head. Circulation, and D - repeated assessment for neurological DEFICIT. This may be due to: • Pressure on the neck veins. Anatomy and Pathophysiology • Increased pressure inside the chest. 0804. The skull is a rigid box containing on October 3, 2021 by guest. Protected copyright. brain, cerebrospinal fluid (CSF) and blood 0805. Rising ICP, brain swelling or vessels: expanding haematomas inside the head can • The brain is surrounded by a series of cause a variety of neurological signs: membranes. The outer, thick membrane is • Pressure of the third cranial nerve called the dura. Beneath the dura is a more (oculomotor) will result in a dilated pupil flimsy membrane called the arachnoid. The on the same side as the injury. CSF flows in the space deep to the • Damage to the motor or sensory cortex (or arachnoid. Bleeds are described as tracts leading from them) will result in a occurring outside or inside these motor or sensory DEFICIT on the membranes hence extradural, subdural and contralateral side to the injury. subarachnoid. • A decrease in level of consciousness is the • Blood is supplied to the brain by the marker of brain injury. Generally, the more internal carotid and vertebral arteries and deeply unconscious a casualty becomes, eventually drains via the internal jugular the more serious is the injury. Coma is a veins. term used for unconsciousness although to • The brain is very active and needs a lot of be accurate it should only be used for oxygen and substrate to survive. Loss of deeply unconscious casualties (see oxygenated blood flow for more than three paragraph 0829). minutes will cause brain damage. • Pressure on the lower part of the brain • Intracranial pressure (ICP) is the pressure (brain stem) where the respiratory and 1.This is not the same as the systolic pressure. 152 BATLS Chapter 8 cardiovascular centres lie, produces brain are amenable to emergency surgery. J R Army Med Corps: first published as 10.1136/jramc-148-02-10 on 1 June 2002. Downloaded from respiratory or cardiovascular abnormalities These conditions must be diagnosed early as (change in heart rate and blood pressure, rapid evacuation to a surgical or change in breathing pattern and rate). neurosurgical unit for early surgery, greatly reduces the morbidity and mortality. 0806. It follows that preventing a rise in intracranial pressure or a fall in cerebral Contusions perfusion is vital in the overall management 0813. These are caused by blunt injury of head injury. This must never be producing acceleration and deceleration forgotten. forces on the brain tissue resulting in tearing of the small blood vessels inside the brain. Brain Injury Contusions can occur immediately beneath 0807. Primary brain injury is the neurological the area of impact when they are known as damage produced by the traumatic event, for coup injuries, or at a point distant from the example, a blow to the head or damage from area of impact in the direction of the applied a gunshot wound. Secondary brain injury is force when they are known as contrecoup the neurological damage produced by what injuries. If the contusion occurs near the follows on from the traumatic event. Causes sensory or motor areas of the brain, these include: hypoxia, reduced cerebral casualties will present with a neurological perfusion, raised ICP, convulsions and deficit. Precise diagnosis requires appropriate infection. imaging (CT scanning), consequently, the Primary Brain Injury treatment is supportive, aimed at the 0808. Primary brain injury may be diffuse or avoidance of secondary brain injury. focal. Intracranial haemorrhage Diffuse Brain Injury 0814. Haemorrhage may arise either from 0809. Blunt injury to the brain may cause meningeal vessels or from vessels within the diffuse brain injury, particularly when rapid brain substance. head motion (acceleration or deceleration) leads to widespread damage within the brain Extradural haemorrhage substance. Such injuries form a spectrum 0815. This is caused by a tear in a dural extending from mild confusion to severe artery, most commonly the middle injury. meningeal artery.This can be torn by a linear fracture crossing the temporal or parietal Concussion bone and injuring the artery lying in a groove 0810. Concussion is a brain injury on the deep aspect of the bone (see Fig 8.1). accompanied by a brief loss of consciousness Isolated extradural haemorrhage is unusual, http://militaryhealth.bmj.com/ and, in its mildest form, may cause only accounting for only 0.5% of all head injuries temporary confusion or amnesia. With mild and less than 1% of injuries causing coma. forms of concussion, most casualties will be The importance of early recognition of this slightly confused and may be able to describe injury lies in the fact that, when treated how the injury occurred. They are likely to appropriately, the prognosis is good because complain of mild headache, dizziness or of the lack of underlying serious injury to nausea. The mini-neurological examination brain tissue. If missed, the rapidly expanding will not show localising signs. With more haematoma causes ICP to rise, reducing severe concussion there is a longer period of cerebral perfusion and leading to cerebral unconsciousness, longer amnesia (for time hypoxia, coma and death. on October 3, 2021 by guest. Protected copyright. both before and after the injury) and there may be focal signs. The duration of amnesia 0816. The typical symptoms and signs of needs to be recorded. extradural haemorrhage are: Diffuse axonal injuries • Loss of consciousness followed by a lucid 0811. At the other end of the spectrum from interval (which may not be a complete mild concussion, diffuse axonal injury is so return to consciousness). severe as to cause a characteristically long • Secondary depression of consciousness. coma, present in 44% of cases. The overall • Dilated pupil on the side of injury. mortality rate is over 30%, rising to 50% in • Weakness of the arm and leg on the its most severe form. The treatment of such contralateral side to the injury. injury involves prolonged controlled ventilation in an intensive care unit, a facility Subdural haematoma that may not be available. Because the 0817. This is more common than extradural mortality is so high, these casualties have a haemorrhage and is found in 30% of all low priority for evacuation. severe head injuries. The mortality rate is up to 60% because, in addition to the Focal Brain Injuries compression caused by the subdural clot, 0812. Brain injuries that produce a contusion there is often major injury to the underlying or haematoma in a relatively small area of the brain tissue. The haematoma can arise from BATLS Chapter 8 153 J R Army Med Corps: first published as 10.1136/jramc-148-02-10 on 1 June 2002. Downloaded from Fig 8.1 Acute extradural haematoma http://militaryhealth.bmj.com/ on October 3, 2021 by guest. Protected copyright. Fig 8.2 Subdural haematoma 154 BATLS Chapter 8 tears in the bridging veins between the cortex Primary Survey J R Army Med Corps: first published as 10.1136/jramc-148-02-10 on 1 June 2002. Downloaded from and the dura or from laceration of the brain 0821. This follows the BATLS A B C D E substance and the cortical arteries (see Fig protocols. For head injury understand: 8.2). Levels of consciousness will vary depending on the underlying brain damage A. Airway. and rate of haematoma formation.The pupil A casualty with a reduced level of on the affected side will become dilated consciousness is likely to have a together with contralateral limb weakness. compromised airway. B. Breathing. Subarachnoid haemorrhage Good ventilation ensures the brain receives 0818.Where haemorrhage has occurred into blood containing enough oxygen and not the subarachnoid space, the irritant effect of excess carbon dioxide.
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