Head injury

HEAD INJURYBy

Dr C.K .Musau.

DEFINITION

• Trauma to the head.

• Neurological disruption.

• Variable presentation.

INCIDENCE

• In the USA, 500,000 new cases

• 10% die before hospital.

• 10% are severe.

• 10% are moderate.

• 80% are mild.

• Many deaths and comorbidities can be reduced through prompt referral .

ANATOMY

• Scalp- five layers: skin, connective tissue, aponeurosis ,loose areolar tissue and pericranium

• skull: cranial vault- smooth, some areas thin. pterion

cranial base is irregular- anterio and middle cranial fossa

• Meninges: three layers. Dura mater,arachnoid and pia.

• Brain –specific functions

ANATOMY(cont)

• Cerebrospinal fluid-30ml per hour, from choroid plexus

• Tentorium- supra and infratentorial compartments .Tentorial incisura edge

closely related to third cranial nerve and uncus

PHYSIOLOGY

• Intracranial pressure –normal 10mmHg or 136 mm water.

Above 20mmhg is abnormal• Monroe Kellie doctrine -brain+blood +csf is a

constant. Initial compensation, eventually exponential rise.

• Cerebral perfusion CPP=MAP-ICP. Perfusion pressure of <70mmhg is critical

• Cerebral perfusion –normal is 50ml/100g of brain

CLASSIFICATION

• Mechanism of injury- blunt or penetrating

• Severity of injury-GCS

• Morphology of injury- skull or intraparenchymal

• Primary or secondary

SKULL FRACTURE

• Linear

• Depressed

• These could be open or closed

PATHOLOGY

• Primary brain injury- at impact

• Secondary-complications-: -haematoma -brain swelling -hypoxia -infection

INTRACRANIAL BLEED

• Epidural

• Subdural

• Subarachnoid

• intracerebral

MANAGEMENT

• History

• Physical examination

• Radiological investigations skull radiograph, cat scan, MRI

PRIMARY SURVEY

• A.-ABCDE

• B-Immobilize and stabilize the cervical spine

• C-Perform a brief neurological exam 1.pupillary response. 2.GCScore determination.

SECONDARY SURVEY

• A-.Inspect the entire head. Remove dressings ,look for lacerations or csf

• B-Palpate for fractures including the wounds• C-Inspect all scalp lacerations-look out for

brain,depressed fractures,debris or csf• D-Minineurological examination--GCS -BEST

- -Eye

-Motor - - Verbal Pupillary response

E-Examine cervical spineF-Determine the extend of the injuryG-Regular reassessment

INVESTIGATIONS

• A-Radiographs• B-CT SCAN

-scalp -bone -subdural/epidural space -surface sulci -brain parenchyma -ventricles -midline structures and basal cisterns -posterior fossa

SPECIFIC MANAGEMENT

• MILD HEAD INJURY-GCS 14 or 15 -Approx 80% of pts in A &E have mild HI

-majority recover fully -3% deteriorate suddenly -ideally, all with long period of loc should have a CT scan -ideally admit for observation for 24 hours -advise to come back in case of any warning signs

MODERATE HEAD INJURY

• GCS 9-13

• Approx 10 % of patients in A&E departm

• May have focal signs.

• 10-20% may deteriorate

• Up to 40% have abnormal scans

• Admit even if CTscan is normal

SEVERE HEAD INJURY

• GCS 3-8• Cannot follow commands• Up to 30% are hypoxaemic-• 13% hypotensive• 12% anaemic• Combination of hypoxia and hypotension

leads up to 75% mortality.• Admit all and protect airway from early

HAEMATOMA-SUBDURAL

• CTscan confirmation

• Indications for surgery: -focal neurological signs -altered loc -features of raised ICP

• Burr holes or craniotomy

EPIDURAL HAEMATOMA

• CT confirmation

• Usually ruptured middle meningeal artery occasionally dural venous sinus rupture

• Indication for surgery –focal signs or raised ICP

• craniotomy

INTRACEREBRAL HAEMATOMA

• Indication for surgery -raised ICP

• Safe access of the haematoma is very important

• Craniotomy

• Deficits may persist

LINEAR FRACTURE

• Simple -no indication for surgery

• Compound- theatre for surgical debridement and stitching

DEPRESSED SKULL FRACTURE

• Closed elevation in case it is significant

• Compond- Theatre for surgical debridement and elevetion

• Antibiotic cover

RAISED ICP

• Ventillatory support

• Mannitol

• lasix

Extradural haematoma

Subdural haematoma

Bilateral subdural haematomaacute on chronic

Bilateral subdural haematoma MRI findings

Brain oedema

Post-craniotomy extradural haematoma

Post-craniotomy extradural haematoma

Intracerebral haematoma with marked brain swelling

Intracerebral haematoma