Initial Assessment of Cranial Trauma

• Treat life-threatening emergencies first!
• Remember the ABC’s – Airway, Breathing, Circulation
• Shock is not caused by head trauma
• Protect the spine
• Initial Exam
• Level of consciousness
• Pupillary response
• Respirations
• Motor function/response to noxious stimuli
• Rectal tone
• Physical findings to note
• Extent of other injuries to prioritize resuscitation
• Scalp lacerations
• Explore with sterile gloved finger
• Bleeding from the scalp can be profuse and life-threatening (especially in children)
• Raney clips can be useful to gain control and are available in the OR
• Evidence of extruded brain
• Battle’s sign
• Ecchymosis and tenderness over mastoid process
• Virtually diagnostic of basilar skull fracture
• Raccoon’s eye
• Periorbital ecchymosis
• Frequently signifies basilar skull fracture in anterior fossa
• Hemotympanum
• CSF otorrhea or rhinorrhea
• Palpable skull fracture/depressions
• A galeal tear can easily be confused with a fracture line
• Skull films/CT remain definitive study in diagnosis
• Assessment of Brainstem Function

Level	Pupils	Cold Calorics	Respirations	Movement
None	Midposition reactive	Nystagmus	Rhythmic	Purposeful
Diencephalon	Small reactive	Tonic conjugate Eye deviation	Cheyne-Stokes	Decorticate
Midbrain	Midposition nonreactive	Disconjugate Eye deviation	Hypervent	Decerebrate
Pons	Pinpoint reactive	None	Apneustic	Flaccid

· Cushing response to increased intracranial pressure

o Increased BP, bradycardia, and irregular respiration

· Acute deterioration or blown pupil may require Mannitol (1g/kg) to buy time until imaging reveals source of injury

· Avoid glucose and free water in all trauma patients

o Use only NS or LR to prevent increasing cerebral edema

Glascow Coma Scale

Eyes	Open	Spontaneous To verbal To pain None	4 3 2 1
Best Motor	To Pain	Obeys verbal Localizes Flexor withdraw Abnormal flexion Postures None	6 5 4 3 2 1
Best Verbal		Oriented Confused conversant Inappropriate words Incomprehensible sounds None	5 4 3 2 1

o Lowest possible score is 3

o While the Glascow Coma Scale remains a useful tool in evaluating the trauma patient, it is more important to consistently document exactly how patient responds in your note rather than that the GCS was a specific number

o Head injury severity based on GCS:

§ Mild head injury – GCS 13-15

§ Moderate head injury – GCS 9-12

§ Severe head injury – GCS 3-8

§ If patient is intubated, verbal response is dropped and designation “T” is appended to the GCS score (maximum score is 10T)

· Quickly assess need for head CT

o Any patient with LOC (even if GCS=15 in ER), altered neuro status, evidence of external head trauma, or who will undergo general anesthesia for other injuries requires uncontrasted head CT

o A hypotensive patient with frank blood on DPL obviously does not need a head CT before surgery

o If patient is unconscious with localizing signs (i.e., blown pupil), exploratory burr holes can be placed in OR without CT to r/o extra-axial hemorrhage

o If patient is awake, head CT can be obtained post-op if indicated

· Patients with evidence of increased intracranial pressure should not undergo general anesthesia unless it is necessary to treat a life-threatening process

o Elective repairs should be postponed until ICP returns to normal levels