• Depressed skull fracture, severely displaced/angulated fracture, open fracture, femoral neck/intertrochanteric fracture o Take straight to the Operating Room o More Angulation after fractures in a child will not lead to permanent deformity • LOC: CT w/o Contrast • Linear skull fractures o Closed: Leave alone o Open: Close o Comminuted or depressed: Operating room • Midface Fractures o Le Fort I – maxilla at the nasal fossa  Unstable maxilla  Diagnosis: CT o Le Fort II – maxilla, nasal bones, medial orbits  Unstable maxilla + Nasal Bone mobility  Incorrect teeth placement  Diagnosis: CT of the face  Management • ENT Consultation o Le Fort III – maxilla, zygoma, nasal bones ± cranial bones  Airway often compromised  “floating” maxilla/face from the rest of the head o Orbital Blowout Fracture  Limited upward gaze, swelling and ecchymosis infraorbitally  Fracture of superior portion of maxillary sinus  Diagnosis: CT o Zygomaticomaxillary-Orbital Complex Fractures  “tripod” fractures • Zygomatic-frontal and temporal sutures and orbital floor • MVA or Assult • Facial flattening, CN V palsy, Trismus, diplopia • Diagnosis: CT • Treatment o Surgical Repair • Intercranial Pressure (ICP) o Normal <15 mmHg, maintain ICP <20 and cerebral perfusion pressure >60  ICP to monitor CPP  CPP = MAP – ICP • Arterial line required for MAP o Increased ICP + Hyponatremia: SAH o Increased ICP  Headache, Nausea, Vomiting, AMS  Cushing’s Reflex • Late stage indicator • Headaches (worse at night), Nausea/vomiting and AMS o ± focal neurologic symptoms, and seizure o Valsalva, leaning forward, cough make it worse • Worrisome finding suggestive of brainstem compression • Hypertension, bradycardia, respiratory depression  Brain Tumors, trauma, cerebral edema, hemorrhage, hydrocephalus, hepatic encephalopathy, impaired venous outflow  Treatment • Emergent treatment if GCS ≤8 + Cushing’s reflex • Elevation of the bed (increase venous flow) • Sedation (control hypertension, decrease demand) • Hyperventilation (decrease CO2, cerebral vasoconstriction) o pCO2 to 26-30 is goal • IV Mannitol (draws fluid from tissues) • CSF Removal (Hyrdrocephalus) • Lidocaine if intubation is needed • Traumatic Brain Injury (TBI) o Biomechanically induced alteration of brain function o Etiology  Accidents > Sports o Symptoms  Amnesia, confusion  Headache, dizziness, and nausea/vomiting immediately following  Mood and cognition changes days to weeks later o Diagnosis: Clinical  Head CT/MRI if: >60 y/o, progressive headache, seizure, repeated vomiting after the trauma, persistent drowsiness or amnesia, focal deficits, dangerous injuries  May have abnormal EEG o Treatment  Mild (Concussion) • Remove from play • Graduated return to play: o Evaluated for recurrence of symptoms while performing stepwise increases in activity o Can return to play if asymptomatic for 7 days w/o meds • Symptomatic for ≥10 days o Neuropsychological testing o Vestibular Therapy  Treatment of head injuries • • Cerebral Contusion o General  Bruising of the brain caused by traumatic head injury  Coup or Contrecoup  Loss of consciousness and severe Headache are common  Brain herniation possible if significant edema o Treatment  Surgery if herniation  Symptomatic treatment otherwise • Cerebral Edema o General  CPP = MAP – ICP = 0  brain death  Causes • Hyperammonemia • Meningitis • Acute Liver Failure • Valproate Toxicity (>180mg/L) • Drowning o Vasogenic Cerebral Edema  Etiology • Surrounding Metastatic brain tumor • V shaped  Increased extracellular fluid 2/2 BBB disruption and increased vascular permeability from endothelial damage causing disruption of tight junctions  May enhance on imaging  ECS expands  Responds to dexamethasone o Cytotoxic Cerebral Edema  Etiology • Head injury, CVA, Hematoma, Circular shape  Increase in intracellular fluid 2/2 neuronal, glial, or endothelial cell membrane injury  BBB intact  No protein extravasation, no enhancement on CT or MRI • Cells swell then shrink o Ischemic Cerebral Edema  Occurs in combination with cytotoxic and vasogenic edema  BBB is closed initially but may open  Fluid Extravasates late  May cause delayed deterioration following intracerebral hemorrhage • Cerebral Edema o Treatment  Steroids/Emergent Decompression  Mannitol  Hypertonic Saline  Therapeutic hyperventilation if unresponsive to other treatment  Head of bed 30 degrees • Posterior Reversible Encephalopathy Syndrome (PRES) o Synonymous Names:   Reversible posterior cerebral edema  Posterior leukoencephalopathy syndrome  Hyperperfusion encephalopathy  Brain capillary leak syndrome o Etiology  Hypertensive crisis •  Cyclosporine  Eclampsia/preeclampsia  Allogenic Bone Marrow Transplantation  Renal Disease  Autoimmune Disease  Sepsis/Shock o Features  Thunderclap headaches not responsive to analgesics  AMS  Visual Disturbances • Hallucinations, cortical blindness  Seizures (generally tonic clonic)  Hemiparesis o Post-partum o Neuroimaging:  Brain MRI w/symmetrical hyperintense T2/Flair signal abnormalities in subcortical posterior parietooccipital white matter  CT • Intracerebral hemorrhage, bilateral vasogenic edema o Treatment  Lowering BP, antiepileptic  Most patients have reversal of symptoms in 2 weeks • Diffuse Axonal Injury o Traumatic acceleration/deceleration shearing forces o Coma with head CT showing diffuse small bleeds at grey-white junction o Fewer than 10% regain consciousness • Intracranial Hemorrhage o Epidural Hematoma (M-MMA)  Etiology • Middle Meningeal Artery disruption o Largest artery that supplies dura • Blood between the dura and the skull o Confined by cranial suture lines • Sphenoid bone MCC/temporal bone next  Symptoms • Initial loss of consciousness after head trauma, followed by lucid interval, then lethargic and comatose • MC in adolescent age range  Hematoma • Increased ICP o Brain begins to herniate  Brief loss of consciousness followed by lucid interval, then lethargy/confusion/coma o Reticular formation compression causes AMS • Possible CN III Palsy 2ndary to transentorial herniation o Ipsilateral hemiparesis, mydriasis, ptosis, down and out, contralateral homonymous hemianopsia  Lumbar puncture is contraindicated (death) o Contralateral hemiparesis  Diagnosis: Non-contrast CT Scan for size and location • White Lens inside (biconvex), does not cross suture lines • Biconvex intense lens shaped hematoma • MRI if CT is inconclusive  Treatment • Urgent surgical evacuation (craniotomy) for symptomatic patient’s w/ hematoma evacuation • Conservative if small  Transentorial (Uncal) Herniation • Compression of the contralateral crus cerebri against the tentorial edge: Ipsilateral Hemiparesis • Compression of the ipsilateral CN III by herniated uncus: Loss of PNS causes mydriasis, ptosis, down and out gaze and ipsilateral pupil due to unopposed CN 4 and 6 actions (late) • Compression of PCA: Contralateral Homonymous Hemianopsia • Compression of Reticular Formation: Altered Level of Consciousness, coma o Subdural Hematoma (B – Bridging Veins) • MC in elderly and alcoholics (atrophied brain ± fall) o Anticoagulant use increases risk • Tearing of bridging veins between dura and arachnoid membrane  Acute Subdural Hematoma • Gradual HA and confusion over 1-2 days, no LOC o Usually <24 hours for symptoms o Vomiting, nausea, focal neuro deficits o Increased ICP • Retinal hemorrhages in children = abuse • White crescent inside • Not confined by cranial suture lines • Diagnosis: Non-contrast CT scan of the head o Hyperintense crescent-shaped lesion, does not cross midline due to falx • Treatment o No Midline Shift/Deviation  Prevent increases in ICP (conservative) o Midline Shift/Neurologic deficits/rapidly expanding  >10mm, midline shift >5mm, herniation • Fixed, large pupil, hemiparesis  Craniotomy and surgical evacuation  Subacute Subdural Hematoma • Usually 1 day – 2 weeks  Chronic Subdural Hematoma • Symptoms >2 weeks • Pale crescent inside • No head trauma history • HA, confusion, seizure, unilateral weakness • Diagnosis: non-contrast CT scan o Hypodense, crescent-shaped lesion that may contain small bright areas • Treatment o Craniotomy for drainage • Subarachnoid • Basilar Skull Fracture o Traumatic, Nasotracheal intubation contraindicated o Periorbital Ecchymosis “Raccoon Eyes”, retroauricular or mastoid ecchymosis “Battle Sign”, clear otorrhea, clear rhinorrhea, Hemotympanum (dark purple or blue discoloration of the tympanic membrane)  1-3 days after the event o Dura mater tears are associated with BSFs  Clear or bloody CSF from the ear or nose o Diagnosis: Non-contrast CT Scan of the head  Check Cervical spine with CT o Treatment  Conservatively, observation  If CSF from the nose (not ear)  Surgical intervention to repair dura mater