Basics
Description
Penetrating injury to intracranial contents:
- High-velocity penetration: Usually bullets, which cause trauma directly to brain tissue and also have a "shock wave"¯ injury to local surrounding brain
- Low-velocity penetration: Usually knives, picks, or other sharp objects, with direct local trauma to brain tissue
Etiology
- Direct penetration of the skull into the intracranial cavity by foreign object:
- Direct or local damage to brain tissue
- Intracranial hemorrhage, including subdural, epidural, and intraparenchymal bleeds
- A bullet that hits the skull, ricochets off, and does not fracture the skull can still cause significant trauma to the underlying brain tissue.
Diagnosis
Signs and Symptoms
- Alteration in level of consciousness and neurologic exam varies based on object and location.
- Evidence of increasing intracranial pressure:
- Decreasing level of consciousness
- Falling Glasgow Coma Scale score
- Cushing response: Bradycardia, hypertension, and diminished respiratory rate
- Blown pupil associated with decorticate or decerebrate posturing
- Evidence of penetrating injury to head or basilar skull fracture, or object still remaining in head:
- Raccoon eyes: Bilateral ecchymosis of orbits associated with basilar skull fractures
- Battle sign: Ecchymosis behind the ear at mastoid process associated with basilar skull fracture
- Hemotympanum
- CSF rhinorrhea or otorrhea
History
- Determine the weapon type or caliber of weapon at scene.
- Loss of consciousness (LOC) or amnesia for event
- Use of anticoagulants
- Headache, visual changes, or hearing loss
- Focal neurologic complaints
Physical Exam
- Evaluation of head for evidence of penetrating injury and if a projectile, for multiple sites
- Complete neurologic exam
- Alteration in level of consciousness and neurologic exam varies based on object and location.
- Evidence of penetrating injury to head
Essential Workup
- Thorough history and exam to assess extent of injuries
- Imaging study
Diagnosis Tests & Interpretation
Lab
- CBC
- Platelet count
- Coagulation perimeters
- Type and cross-match
- Electrolytes, BUN, and creatinine baseline levels
Imaging
- CT of head depicts location of lesion and extent of damage.
- Skull radiographs may reveal depth of impalement, location of bone fragments, and presence of fragments within the cranium.
- Cervical spine evaluation (when indicated):
- Helical CT scanning or anteroposterior, lateral, and odontoid views plain radiographs
Differential Diagnosis
- Blunt head trauma
- Basilar skull fracture
- Any condition that alters mental status that may have induced a fall and caused secondary penetrating trauma
Treatment
Pre-Hospital
- Stabilize but do not remove foreign object (e.g., knife).
- Determine the weapon type or caliber of weapon at scene.
- Protect and manage the airway to avoid hypoxemia.
- Avoid hyperventilation.
- Maintain cervical spine precautions.
- Transport to trauma center.
- Avoid hypoxia (oxygen saturation <90%):
- Avoid hypotension (systolic BP <90 mm Hg):
- Administer IV crystalloid solutions
Initial Stabilization/Therapy
- Management of ABCs
- Rapid sequence intubation:
- For Glasgow Coma Scale score <8, inability to protect airway, hypoxia, or cerebral herniation
- Medications include etomidate or fentanyl as induction agent, succinylcholine (pretreat with minidose paralytic), rocuronium, or vecuronium; and morphine sulfate for ongoing sedation
- Caution with fentanyl in the hemodynamically labile patient
- Normalize Pco2. Avoid hyperventilation or hypoventilation.
- IV catheter placement
- Crystalloid solution to maintain systolic BP >90 mm Hg
- Address other sources of associated trauma.
- Cervical spine precautions should be maintained.
Ed Treatment/Procedures
- Early neurosurgical consultation
- If patient has evidence of cerebral herniation (see Signs and Symptoms), initiate measures to decrease intracranial pressure:
- Mild hyperventilation: 20 breaths/min in adults, 25 breaths/min in children, and 30 breaths/min in infants <1 yr to keep ETCO2 about 30-35 mm Hg.
- Elevate head of bed 20-30 °.
- Mannitol boluses IV: Do not administer mannitol unless systolic BP >100 mm Hg and patient is adequately fluid resuscitated.
- Phenytoin intravenously to prevent early post-traumatic seizures
- Reverse hypocoagulable states
- Glucocorticoids are not recommended to lower intracranial pressure in head trauma patients.
- Barbiturates are not recommended in the initial ED treatment.
- Transfuse as needed to keep hematocrit >30%.
- If definitive neurosurgical care is not immediately available, a single burr hole may preserve life until neurosurgical intervention can be attained:
- Perform only in comatose patients with decerebrate or decorticate posturing who have not responded to initial treatment on the side of a known mass lesion/hematoma.
- Avoid hypothermia, which will increase risks of coagulopathy during surgery.
- Maintain NPO status.
- Surgery:
- Based on clinical and radiologic findings and neurosurgical consultation
Medication
For RSI intubation, increased ICP, seizures, and pain control
First Line
- Etomidate: 0.2-0.3 mg/kg IV
- Fentanyl: 3-5 Ī¼g/kg IV:
- If systolic BP >100 mm Hg
- Mannitol: 0.25-1 g/kg IV bolus
- Morphine sulfate: 2-20 mg IV (peds: 0.1 mg/kg up to adult doses)
- Phenytoin: 15-20 mg/kg IV up to 1,000 mg
- Rocuronium: 0.6 mg/kg IV
- Succinylcholine: 1-2 mg/kg IV
- Vecuroniumbromide: 0.1 mg/kg IV:
- Pretreatment minidose: 0.01 mg/kg IV
- Vitamin K:
- To be used in patients on Coumadin with intracranial hemorrhage
- 10 mg in 50 mL NS infused over 30 min
- Protamine sulfate:
- To be considered if taking low molecular weight heparin (LMWH) with intracranial hemorrhage
- If LMWH used <8 hr prior, use 1 mg protamine for each mg of LMWH slow IV push over 1-3 min
- If LMWH used >8 hr prior, use 0.5 mg protamine for each mg of LMWH slow IV push over 1-3 min
Follow-Up
Disposition
Admission Criteria
Admit all patients to ICU or transport directly to surgery.
Discharge Criteria
Do not discharge.
Followup Recommendations
All patients with penetrating skull injuries should have been admitted.
Pearls and Pitfalls
- Failure to query about anticoagulant use and image appropriately
- Failure to aggressively reverse hypocoagulable states
Additional Reading
- Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12(suppl 1):S1-S52.
- Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. XV. Steroids. J Neurotrauma. 2007;24(suppl 1):S91-S95.
- Committee on Trauma. Head Trauma: Advanced Trauma Life Support. 8th ed. Chicago, IL: American College of Surgeons, 2008.
- Espinosa-Aguilar A, Reyes-Morales H, Huerta-Posada CE, et al. Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury. J Trauma. 2008;64(5):1327-1341.
- Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents-second edition. Pediatr Crit Care Med. 2012;13(suppl 1):S1-S82.
- Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(suppl 2):e737S-801S.
- Warner KJ, Cuschieri J, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma. 2007;62(6):1330-1336.
See Also (Topic, Algorithm, Electronic Media Element)
- Head Trauma, Blunt
- Spine Injury: Cervical, Adult
Codes
ICD9
- 803.60 Other open skull fracture with cerebral laceration and contusion, unspecified state of consciousness
- 803.90 Other open skull fracture with intracranial injury of other and unspecified nature, unspecified state of consciousness
- 854.10 Intracranial injury of other and unspecified nature with open intracranial wound, unspecified state of consciousness
- 803.50 Other open skull fracture without mention of injury, unspecified state of consciousness
ICD10
- S02.91XB Unspecified fracture of skull, init encntr for open fracture
- S06.2X0A Diffuse TBI w/o loss of consciousness, init
- S06.330A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter
SNOMED
- 28188001 Brain injury with open intracranial wound
- 371161001 Open fracture of skull (disorder)
- 111617009 Open skull fracture with intracranial injury (disorder)
- 90898001 Open skull fracture with cerebral laceration AND/OR contusion (disorder)
- 4807003 Open skull fracture without intracranial injury (disorder)