1. Approach to
Head-Injured Patient
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คณะพยาบาลศาสตร์ มหาวิทยาลัยมหิดล

2. Cerebral Blood Flow (CBF)
O2 concentration 
 CO2
 CO2
vasodilator
vasoconstriction
dilation of
cerebral vessels
 CBF
 BF
 BF
 Blood volume
 Blood volume
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3. Intracranial Pressure (ICP)
 Cranial vault: Brain 80% + Blood 10% +
Cerebrospinal fluid 10%
 Normal intracranial pressure 10 mmHg
 Pressure > 20 mmHg is abnormal
  ICP   CBF and  cerebral perfusion
“Monro-Kellie hypothesis”
one volume expands…
one or both of the other 2 volumes must decrease
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4. Cerebral Perfusion Pressure
CPP = MAP - ICP
 CPP < 70 mmHg is associated with poor
outcome brain injury.
 A systemic mean arterial pressure is 60-180
mmHg
 Cushing response = cerebral ischemia;  SBP,
wide PP, reflex bradycardia
  SBP, maintain CPP do not  ICP
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5. Mechanism of injury
Injury to the head
Sudden deceleration
Impact pressure wave
Shearing, tensile,
compressive stresses
Coup injury
Contrecoup injury
Hemorrhage,
hematomas, contusions
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6. Pathophysiology
Injury
Primary injury
Hypercarbia,
cerebral edema,
 ICP,
hypotension,
hypoxemia,
Fracture, hematoma
Initial damage
Autoregulation 
Secondary injury
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Compensatory
mechanism

7. Pathophysiology of head injury
Secondary injury
Primary injury
to days following the
• Directly by the
primary injury
external force
• Cellular damage;
• Injury evident
on P/E and CT
scan
• Occurs in the hours
• Lack of oxygen
delivery
• Increased ICP
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8. Secondary injuries
 Hypoxia
 Deceased oxygen supply increased cerebral
blood volume, increasing ICP
 Hypercapnia
 CO2 is a potent cerebrovasodilator, increase
cerebral blood flow and increased ICP
 Hypotension
 Overall blood loss contributes cerebral
hypoperfusion
 Intracranial hypertension
 Cerebral edema leads to increased ICP
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9. Cerebral ischemia
CPP 
Autoregulation
Failure of autoregulation
Vasoconstriction / Vasodilation
• cerebral vasodilation,
•  blood brain volume,
• cerebral engorgement
 ICP & CPP
Maintain CPP
• cerebral edema,
•  blood brain volume,
•  ICP, CPP
Cerebral ischemia
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10. Cerebral ischemia
Cerebral ischemia
 CO2 concentration /  O2 concentration
CO2 dilates cerebral blood vessels
 blood brain volume
•
•
•
•
•
Headache
Nausea, vomiting
Amnesia
Altered LOC
Restless, change
in speech, loss of
judgment
•
 ICP
Early signs & symptoms
Late signs
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•
•
•
•
•
•
Dilate,
nonreactive pupil
Unresponse to
V/P
Abnormal motor
Change in RR
 SBP
Widened PP
 PR

11. Categories of
traumatic brain injury
Focal brain
Diffuse brain
injury
injury
• Cerebral
contusion,
epidural,
• concussion,
• Diffuse
axonal injury
subdural,
Skull fractures
• Linear,
depressed,
comminuted,
basilar
intracerebral
hematoma
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12. Epidural hematoma
 Is a focal brain injury resulting in a collection
of blood between the skull & dura mater
 Require immediate surgical intervention.
 Signs & symptoms:
 Initial  LOC followed lucid interval  rapid
unconscious
 Persistent  LOC
 Hemiparesis or hemiplegia
 Unilateral fixed or dilated pupil.
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13. Subdural hematoma
 Is a focal brain injury beneath the dura mater
 Signs & symptoms:
 Steady decline in LOC
 Hemiparesis or hemiplegia
 Unilateral fixed or dilated pupil.
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14. Subdural hematoma
Acute SDH
• Occurs within 48
hrs of initial injury
• Present with loss
Sub acute SDH
• Develops 2-24
Chronic SDH
• Apearent several
days after initial
weeks to months
injury
after initial injury
of consciousness
• Headache,
and deteriorating
confusion,
GCS
speech deficits
be developed if
• Required
hematoma
emergent
enlarges
craniotomy for
evacuate of the
thick, coagulated
blood
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15. Category of head injury
Mild
Moderate
Severe
head injury
head injury
head injury
• GCS = 13-15
• GCS = 9-12
• associated with
• associated with
• GCS less than
or equal to 8
loss of
a loss of
consciousness
consciousness
loss of
or amnesia for
for up to a day
consciousness
less
• associated with
for more than
24 hours
• than 1 hour
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16. 1survey to head-injured patient
Step 1
Step 2
ABCDE
Immobilize
Step 3 Brief
neurological exam

17. 2survey to head-injured patient
Step 1
Inspect
entire head
Step 6
Document
Step 2
Step 5
Palpate
Examine
entire head
cervical spine
Step 3
Step 4
Inspect
Determine
all scalp
GCS
Step 7
Reassess
& observe

18. Those older than 65 years of age
•
are at increased risk of bleeding from head
injury because the aging brain shrinks away
from the skull, causing the veins that bridge
from the skull to the brain surface to be more
easily torn.