Head injuries Overview

CROSS-SECTION

HEAD INJURY - DEFINITION

• Any injury that results in trauma to the SCALP,

SKULL or BRAIN.

• TRAUMATIC BRAIN INJURY and HEAD

INJURY are often used interchangeably.

HEAD INJURY - TYPESOPEN HEAD INJURY:

There is penetration to the skull.CLOSED HEAD INJURY

There is NO penetration to the skull.

COUP-CONTRECOUP INJURIES

• Damage may occur directly under the site of impact (COUP), or it may occur on the side opposite the impact

(CONTRECOUP).

HEAD INJURY - MECHANISMS

PRIMARY INTRACRANIAL INJURY

• It is the initial neuronal damage that occurs

IMMEDIATELY as result of trauma.

SECONDARY INTRACRANIAL INJURY

• Secondary injuries are the result of the

neurophysiological and anatomic changes, which occur from MINUTES to DAYS after the original

trauma.

HEAD INJURY - MECHANISMS

PRIMARY INTRACRANIAL INJURY

• Cerebral Laceration• Cerebral Contusion• Epidural Hematoma• Subdural Hematoma

• Subarachnoid Hematoma• Intracerebral Hematoma• Diffuse Axonal Injury

SECONDARY INTRACRANIAL INJURY

• Edema

• Impaired Metabolism

• Altered Cerebral Blood Flow

• Free Radical Formation

• Excitotoxicity

SCALP INJURIES

LACERATIONS SUBGALEAL HEMATOMA

SKULL INJURIES

CLOSED FRACTURES

• A closed fracture has a significant chance of

associated intracranial haematoma.

OPEN FRACTURES• Open fractures have

potential for serious infection.

• Any foreign matter impaled in the skull should be left in place for removal by the neurosurgeons.

• Cover it lightly with a sterile dressing that has been moistened with a sterile saline.

SKULL INJURIES

CT SCAN OT

SKULL INJURIESDEPRESSED FRACTURES/COMPOUND

DEPRESSED FRACTURES NON-DEPRESSED LINEAL FRACTURES

SKULL INJURIES - BASILAR SKULL FRACTURE

SKULL INJURIES - BASILAR SKULL FRACTURE

RACCOON EYE

SKULL INJURIES - BASILAR SKULL FRACTURE

BATTLE’S SIGN

SKULL INJURIES - BASILAR SKULL FRACTURE

BLEEDING FROM THE EAR CANAL CSF LEAKAGE FROM THE EAR OR NOSE

BRAIN INJURIES

DIFFUSE

• Concussion• Diffuse Axonal Injury

FOCAL

• Contusion• Brain Lacerations

• Epidural haematoma• Subdural haematoma

• Subarachnoid haemorrhage• Parenchymal haematoma

HEAD INJURY (DIFFUSE) - CONCUSSION

• Brain injury that does not result in any

evidence of structural alteration.

• Return of consciousness moments or minutes

after impact.

• There may be brief confusion,

disorientation, headache, dizziness,

amnesia.

• CT scan is normal.

HEAD INJURY (DIFFUSE) - DIFFUSE AXONAL INJURY

BRAIN CONTUSION

EPIDURAL HEMATOMA

SCHEMATIC CT SCAN

SUBDURAL HEMATOMA

SCHEMATIC CT SCAN

SUBARACHNOID HEMATOMA

SCHEMATIC CT SCAN

INTRACEREBRAL HEMATOMA

SCHEMATIC CT SCAN

HEMATOMAS

CEREBRAL EDEMA

NORMAL CT SCAN CEREBRAL EDEMA

SIGNS

A sign of ↑ICP (INTRACRANIAL PRESSURE)

CUSHING REFLEX

↑ Blood Pressure

↓ Pulse Rate

↓ Respiratory Rate

SIGNS

• A UNILATERAL , FIXED DILATED PUPIL indicates neurologic deterioration

may be secondary to hypoxia, hypovolaemia or

hypoglycaemia, due to ↑ICP, and compression of

the 3rd Cranial Nerve (OCULOMOTOR NERVE).

DILATED PUPIL

SIGNS

SIGNS

DECORTICATE POSTURING• Arms Flexed

• Arms bent inward on the chest

• Hands clenched into fists• Legs Extended

• Feet turned Inward• Score of 3 in the Motor

section of the Glasgow Coma Scale

SIGNS

DECEREBRATE POSTURING• Head is arched back

• Arms Extended by the sides• Legs Extended

• Patient is rigid with the teeth clenched.

• Score of 2 in the Motor section of the Glasgow

Coma Scale

SYMPTOMS

• Confusion/Irritibility

• Drowsiness

• Dizziness

• Nausea & Vomiting

• Amnesia

• Speech/Swallowing Difficulty

• CSF Leakage

• Ear Bleeding

• Numbness/Paralysis

• Coma

SYMPTOMS

SYMPTOMS

DIAGNOSIS

HISTORY

PHYSICAL EXAMINATION

HEAD & NEUROLOGIC EXAM

CT SCAN

DIAGNOSIS - HISTORY

PATIENT

PEOPLE

DIAGNOSIS - PHYSICAL EXAMINATION

ABCDE• A = AIRWAY

• B = BREATHING

• C = CIRCULATION

• D = DISABILITY

• E = EXPOSURE

• GLASGOW COMA SCALE (GCS)

• SYSTEMIC EXAMINATION

GLASGOW COMA SCALE

MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15

GLASGOW COMA SCALE (GCS)

SEVERITY SCORE

13-15

9-12

3-8

MILD

MODERATE

SEVERE

GLASGOW COMA SCALE (GCS)

SEVERITY LOSS OF CONSCIOUSNESS

0-30 mins

>30 mins to <24 hrs

>24 hrs

MILD

MODERATE

SEVERE

DIAGNOSIS - HEAD AND NEUROLOGIC EXAM

HEAD EXAM• Hematoma

• Contusion

• Fracture e.g. Basilar Skull Fracture

• Laceration

NEUROLOGIC EXAM• Cranial Nerves

• Muscle Tone

• Muscle Power

• Sensations

• Walking Gait

DIAGNOSIS - OTHERS

X-RAYS / MRI

ANGIOGRAPHY

EEG

TRANSCRANIAL DOPPLER

TREATMENT

ACUTE STAGE

CHRONIC STAGE

TREATMENT - ACUTE STAGE

CERVICAL IMMOBILIZATION

• Philadelphia Collar

TREATMENT - ACUTE STAGE (AIRWAY)

ENDOTRACHEAL INTUBATION

• If intubation is impossible: Laryngeal Mask or Cricothyrotomy are

indicated.

SIGNS OF ↓OXYGEN• Respiratory rate < 10 or >40

bpm.

• S02 <90% breathing oxygen or <85% breathing air

• Hypercarbia that implies pH<7.2

• Hypoxia Pa02<50 mm Hg

TREATMENT - ACUTE STAGE (AIRWAY)

LARYNGEAL MASK

TREATMENT - ACUTE STAGE (AIRWAY)

CRICOTHYROTOMY

TREATMENT - ACUTE STAGE (AIRWAY)

ENDOTRACHEAL INTUBATION

• Rapid sequence intubation is performed, using sedative

agents and muscle relaxants.

MECHANICAL VENTILATION STANDARD PARAMETERS

• Tidal Volume: 8-10 ml/kg

• Rate: 12-15 bpm

• Pressure: 15-20 cm H20

• Fi02: 1

TREATMENT - ACUTE STAGE (BREATHING)

• Start high-flow oxygen administration (10-12 l/min)

TREATMENT - ACUTE STAGE (CIRCULATION)

• Establish IV access with two large-bore(14- or16

gauge) IV cannulas.

• IV infusion of Normal Saline (NS).

• IV Norepinephrine

• AVOID giving 5% Dextrose unless hypoglycaemia is

present.

• Dextrose ↑cerebral oedema

• If BP is normal AVOID giving excessive volumes of fluids

that may ↑cerebral oedema.

TREATMENT - ACUTE STAGE (DISABILITY)

TREATMENT FOR ↑ICP

• IV Mannitol (Osmotic Diuretic)

• IV Furosemide

• Hyperventilation

TREATMENT - ACUTE STAGE (DISABILITY)

TREATMENT FOR ↑ICP

• If there are no counter-indications (hypovolaemia,

spine injury) place the patient in “Reverse-Trendelenburg”

position

REVERSE-TRENDELENBURG

TREATMENT - ACUTE STAGE (DISABILITY)

• If significant agitation and after excluding hypoxia, hypovolaemia or pain, as the cause of

agitation: IV Midazolam

TREATMENT - ACUTE STAGE (EXPOSURE)

• AVOID ↓Body Temperature

• ↑Body Temperature: Cooling measures and

IV Paracetamol

• Pain medication: IV Fentanyl

• Anti-Emetics

• Post-Traumatic Seizures: IV Diazepam

TREATMENT - ACUTE STAGE (PARAMETERS)

MONITOR• Blood Pressure

• Heart Rate

• Respiratory Rate

• S02, Etc02

• ECG

BLOOD SAMPLES

• Serum Electrolytes

• Arterial Blood Gas

• Hyper/Hypoglycaemia

TREATMENT - ACUTE STAGE (CATHETERIZATION)

NASOGASTRIC TUBE• Place a Nasogastric tube

(NG Tube) to decompress the stomach and reduce the

risk of vomiting as aspiration.

• AVOID NG Tube for patients with facial injuries. The tube

could enter the brain through a bony fracture.

TREATMENT - ACUTE STAGE (CATHETERIZATION)

URINARY CATHETER

• Insert an indwelling urinary catheter for hourly urine

output monitoring.

• AVOID insertion if injury is suspected to the urethra.

TREATMENT - ACUTE STAGE (SURGERY)

DECOMPRESSIVE CRANIOTOMY

TREATMENT - CHRONIC STAGE

REHABILITATION

Physiotherapy

Neurologists

Occupational Therapy

Speech and Language Therapy

Psychologists/Psychiatrists

COMPLICATIONS• Personality Changes

• Hypopituitarism e.g. DI

• Post-Traumatic Seizures

• Infections e.g. Meningitis

• Vasospasm, Aneurysm

• Coma, Brain Death

LONG-TERM EFFECTS• Parkinson’s

• Alzheimer’s Dementia

PREVENTION

HELMETS

SEAT BELTS

FALLS IN THE ELDERLY

RESTRICTING ALCOHOL USE