Head Trauma

PHTLS Lecture Notes

These notes are designed to be used to accompany the standard PHTLS slides for the 45 minute Head Trauma lesson.
The time under each section title is the time at which that section should be starting. Note that we shoot for 40 minutes to trap overflow.

Introduction

0:00
Slide: Review objectives [8.3]
Take from slide
Slide: Head injury statistics [8.4,8.5]

Anatomy and Physiology

2:00
Slide: A and P of head and brain [8.6]
Layers inner to outer: pia, arachnoid, dura, skull
Slide: Potential spaces [8.7,8.8]
Define "potential space" - nothing there, but can expand to hold fluid/air. Example of empty balloon.
Note blood vessels that can leak into spaces.
Slide: Anatomy of brain [8.9]
Slide: Pathophysiology [8.10,8.11]
Take most from slide. Summarise - balancing act:
Slide: Intercranial pressure [8.12]
"Pouring a quart into a pint pot" -- pressure increases within skull but no real escape. Pressure goes onto blood vessels, blood flow to brain decreases, brain rot sets in.
Slide: Autoregulation [8.13]
Brain's primary aim is to get oxygen. BP increased to increase blood flow to brain ("fight" against the ICP).
Resp system also stimulated to breathe deeper. Pulse slows. Eventually brain herniates.

Head Trauma Levels

12:00
Slide: Level 1 Trauma [8.14]
Arms and wrists come in, legs go out.
Cheyne Stokes: slow and shallow to fast and deep, to slow and shallow
Slide: Level 2 Trauma [8.15]
Everything pushes out. Classic - boxer after hard head blow.
Central neuro hypervent - very fast, shallow "panting"
Looking at permanent neuro damage
Slide: Level 3 Trauma [8.16]
Patient is well gone - "gorked".
Breathing can be effectively random, rhythmless.
Useful to note which side of body goes flaccid first as this can tell neurosurgeons where to look
Slide: Pitfalls [8.17]
Key to effective management is to recognise and react to a changing LOC
Slide: Stages of increasing ICP [8.18]
Review three levels.
Slide: Cushing's Triad [8.19]
BP up, pulse down, resp change -- explained reasons earlier.

Assessment

20:00
Slide: Components of assessment [8.20]
Take from slide. Emphasise noting of change in LOC
Slide: AVPU [8.21]
Quick and dirty, but effective. Note effects of drugs / alcohol
Get class feedback on their experiences.
Note that pain can increase ICP.
Slide: GCS [8.22,8.23]
Cover scores. Summarise as 8-9 score getting serious.
Usually to be done once patient ABC stable, en route

Scenarios

27:00
Slide: Motorcycle crash [8.24]
Note how hard it is to damage a helmet!
Get feedback on kinematics, approach
Slide: Findings [8.25,8.26]
Give signs from slide. Get feedback on problem (possible Level 2 trauma from pupils, resp.)
If so, note possible permanent neuro damage
Slide: Basketball knockout [8.27]
Take scenario from slide
Note duration of u/c
Slide: Findings [8.28]
Note all OK, but too long u/c.
Recommend strongly screening in hospital. If refuse, get them to sign off, give a head injury card, talk to friends (don't let her be alone!)
Slide: Second motorcycle [8.29]
Note: lucid period indicates a probable epidural bleed. 20% of these patients die!
Slide: Findings [8.30]
Get feedback from class.
Note Cushing's Triad, level 1 head trauma
Slide: Softball injury [8.31]
Long lucid period implies subdural, subacute
NB: not that important, just get that airway and O2 going!

Summary

39:00
Slide: Summary [8.32]
High index of suspicion and aggressive treatment required.

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