Thanks for joining me
on this discussion of
traumatic brain injury under
the section of trauma.
Let’s start with a
Take a look at this picture.
The driver, a 25-year-old man,
sustained a high-speed roll-over motor
vehicle accident who now arrives in
your trauma bay, is not responsive.
Do you know what to do next?
I’ll give you a second
to think about it.
Remember, back to our previous initial
assessment and management discussion,
always begin with the ABCs.
Now that you’ve ascertained
an intact airway,
a breathing patient and a patient
who has intact circulation,
we move to the D of disability where
we ascertain a Glasgow Coma Scale.
The Glasgow Coma Scale
has three components.
It’s a global assessment of the
patient’s neurological status.
Take a look at this table.
You’ll notice that there are columns for
eye, verbal, and motor examinations.
The coordinated effort of the patient
who is able to open their eyes,
speak to you, and move their extremities
is one that is an oriented patient.
Glasgow Coma Scales are scored from a
minimum of 1 to a maximum of 6 points.
We assign the best exam finding.
Remember, the best exam finding.
When presented on an examination
of what is the GCS score,
always look for the
best exam finding.
The eye exam is
listed from 1 to 4.
The verbal examination
is listed from 1 to 5.
And the motor exam is
listed from 1 to 6.
There is no precedence or importance
of one exam over another,
although it appears that
motor is heavily weighted.
Important to remember that
you just have to spend a
few minutes looking at the
slide and memorizing.
Unfortunately, I don’t have any simple
ways of memorizing the GCS EVM scoring.
The patient does not open his
eyes, respond verbally or move.
My question to you is, “What is
this patient’s Glasgow Coma Scale?”
Again, the patient
doesn’t open eyes,
has absolutely no verbal
and is not moving at all.
This is a common trick question.
The minimum GCS is 3 because the
lowest score is 1 on a 1 to 6 scale.
So, the minimum score GCS is 3 in
this completely comatose patient.
As a side note, if the
patient is intubated,
clearly you can not assess the verbal but
remember that gestalt is very important.
The placement of the ET
tube, if that’s the only
limiting factor for
patient’s ability to speak,
we assign a T for endotracheal
tube at the end of the GCS score.
Let’s transition to a
discussion of traumatic
brain injury but first
let’s discuss the anatomy.
On this image, you see the first layer
as the skull and right underneath it
is the superior sagittal sinus
containing venous drainage blood.
The yellow outline suggests a subarachnoid
space between 2 arachnoid and pia maters.
I’d like to start the discussion
of specific traumatic
brain injuries with a discussion
of subdural hematomas.
hematomas or any intracranial
bleeding is associated with
high impact to the skull.
They are traditionally associated
with tearing of bridging
veins between the brain
surface to the dura sinus.
As you can see in this image,
bleeding in the subdural
space results in a semilunar
or often called moon-shaped
The reason is because the blood separates
the arachnoid away from the dura.
It is not, however, bound
by the sagittal sinuses.
There may or may not be medial deviation
or elevation of the intracranial pressure.
Remember, any space-occupying
lesion in the brain
may lead to elevations of
We will come back
to this concept.
How do we manage subdurals?
Based on the clinical status and
the severity of the subdural,
management is guided by midline
shift, intracranial hypertension,
clinical picture such as a
comatose or worsening GCS patient
or particularly large subdural
hematomas as defined by
bleeding hematomas greater than
one centimeter in thickness.
If these findings are present,
consider calling a neurosurgical
colleague for surgical
decompression of the hematoma.
Of course if the patient doesn’t have
any of these significant findings,
then our job as trauma surgeons
is to prevent secondary injury.
What does it mean to
prevent secondary injury?
With any trauma, just like when you bang
your knee, some swelling is bound to happen.
We want to decrease swelling and also prevent
ischemia or low perfusion of your brain.
Let’s move on and discuss
Once again, epidural hematomas are
associated with high impact to the skull.
Unlike subdurals which are
associated with bridging veins,
the epidurals are associated
with middle meningeal artery.
In a clinical scenario, this often
describe classic lucid interval
where the patient immediately following
the trauma may actually be lucid
and after about 30 minutes to an
hour has a second comatose episode.
I caution the viewer though
that the classic lucid
interval is much more disgusting
and seen in real life.
And seen on this CAT scan, you
notice that the lenticular
shape or biconvex shape which
is limited by the suture line.
How do we manage an
Most epidural hematomas, unlike subdural
hematomas, require a surgical decompression.
If a clinical scenario is
presented to you where a
patient sustains high
velocity or a high-impact
brain trauma and they
demonstrate a lucid interval,
I encourage you to hold
epidural hematomas high on your
differential list and a list
of surgical decompression.
Once again, like any
traumatic brain injury,
we want to try to prevent
Let’s discuss skull fractures.
Once again, skull fractures
are associated with
high-impact mechanisms such
as an assault with a weapon.
It’s a classic scenario to
have a patient undergo assault
with a bat or a metal instrument
direct blow to the head.
Remember that skull fractures are often
associated with cervical spine injuries.
This likely has to be dissociation
due to the high impact injury.
Some very important
classic signs include the
raccoon’s eyes which is a
bruising around the eyes.
Remember, raccoon eyes and battle’s signs
are signs of a basilar skull fracture.
Battle’s sign is bruising
around the mastoid process.
Just to review, raccoon’s eyes is
bleeding or bruising around the eyes
and battle’s sign is bruising of the
mastoid process just behind the ear.
And depending on the severity, the patient
can have a CSF, cerebrospinal fluid leak.
Most skull fractures
are largely managed
couple of caveat exists.
depression of the skull.
This may require
elevation of the skull.
And most importantly,
an open skull fracture
exploration and elevation.
Earlier, I mentioned that one
of the clinical signs to
evaluate the patient for is
intracranial pressure monitoring
and to try to prevent intracranial
hypertension for high ICPs.
A very useful and practical equation to
remember is the cerebral perfusion pressure.
The cerebral perfusion pressure is a
difference between the mean arterial pressure.
That’s the systemic circulation
minus the intracranial pressure.
Again, the cerebral
perfusion pressure is a
difference between your
MAPs and your ICPs.
In severe TBI patients where their GCS
is less than 9 were considered comatose.
Intracranial pressure monitoring may help
with diagnosis of further deterioration.
patients will not likely
participate in your
Patients in whom we cannot
follow the examination,
for example, a comatose patient
or one who is on severe sedation
or anesthesia may also require