1.
HEAD INJURIES
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2.
objectives
1.To acquire knowledge about head trauma
2.To be capable of managing patients with
head injuries
3.To give prognosis of patients with head
injuries.
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3.
outline
• Introduction
• Definition
• Causes
• Classification
• Management
• Complications
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4.
INTRODUCTION
• Head injury is one of the commonest causes
for attending accident in the emergency
department.
• It accounts for 1% of all deaths, 25% of
deaths due to trauma and is responsible for
50% of all deaths from road trafic
accidents(RTA)
• Many pts. who die or disabled belong to the
younger age groups.
• The mortality doubles if there is airway
obstruction with hypoxia and shock.
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5.
DEFINITION
• Head injury can be defined as any
alteration in mental or physical
functioning related to a blow to
the head.
• Loss of consciousness does not
need to occur
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6.
CAUSES OF HEAD INJURY
1. Road traffic accidents
2. Bullets
3. Falls
4. Assault
5. Blast injuries from incendiary
devices can cause head trauma and
primarily occur in soldiers
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7.
Classifications of head
injury
• It can be classified based on :
I. Glasgow Coma Score (severity)
II. Mode of injury
III. Mechanism of production of the injury
IV. Pathological changes on the brain
tissue due to the trauma
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8.
Classification of head injury according
the GCS (severity)
1. Minor head injury (GCS 15 w/o LOC)
2. Mild head injury (GCS 14 or 15 with LOC
3. Moderate head injury (GCS 9-13)
4. Sever head injury (GCS 3-8)
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9.
Classification of head injury based on
mode of injury
1. Open (penetrating) head
injury(missile injury of high velocity
or stab wound)
2. Closed(blunt)head
injury(acceleration / deceleration &
rotation)
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10.
Classification of head injury based
on its mechanism of production
1. Direct injury
2. Acceleration / deceleration or rotation
injury
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11.
Classification of head injury based on pathological
changes on the brain due to trauma
I. Primary lesions
1) Concussion
2) Contusion
3) Laceration
II. Secondary brain damages (injuries)
1. Swelling(edema) due to venous congestion and hypoxia
2. Intracranial hemorrhage causing compression on brain
tissue
3. Infections:
 Meningitis
 Subdural empyema
 Pott's puffy tumour
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12.
Causes of secondary brain injury
■ Hypoxia: PO2 < 8 kPa
■ Hypotension: systolic blood pressure (SBP)<
90 mmHg
■ Raised intracranial pressure (ICP): ICP > 20
mmHg
■ Low cerebral perfusion pressure (CPP): CPP
< 65 mmHg
■ Pyrexia
■ Seizures
■ Metabolic disturbance
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13.
SCALP LESIONS
• Can be :
1. Incised wound
2. Contusion
3. Laceration
• Clinical features:
 Disruption of continuity
 Swelling
 Bleeding
• Investigations:
 Skull x-ray PA & lateral to R/o underlying skull
fracture
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Treatment of scalp lesions
1. TAT. after skin test(if open wound)
2. Stop bleeding(if bleeds), thorough debridement
and cleaning with H2O2 3% & N/S
3. Wound suturing under L /A (if <6hrs.)
4. Analgesics
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15.
FRACTURE OF THE SKULL
• May involve the:
1. Vault:
• SIMPLE (closed) OR COMPOUND(OPEN)
• Linear or comminuted
• Depressed or non-depressed
• Stellate
2. Base:
 Anterior fossa
 Medial fossa
 Posterior fossa
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16.
Clinical features of skull fractures
 Swelling / scalp wound
 Bleeding from the ear (ottorrhea) and / or bleeding
from the nose (rhinorrhea)
 Subconjuctival haemorrhage
 Bruising of the mastoid process’s area ( Battle’s
sign)
 Signs of cranial nerves’ injuries:
Anosmia (olfactory nerve injury)
Facial palsy (facial nerve injury)
Deafness (auditory nerve damage)
Blindness (Optic nerve lesion) or
dilated or constricted pupils DUE TO
3rd. Cranial nerve lesion etc.
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Investigation for skull fracture
• SKULL X- RAY PA & LATERAL
• CT-scan / MRI
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Treatment of skull fracture
• Initial assessment following the A B C D E
rule
• If linear fracture : no need of Rx.
• If simple depressed fracture : elevation
• If compound depressed : remove debris,
clean with H2o2 3% and N/s and elevate.
• If basal fractures : antibiotics &
• Rhinorrhea : no nose blowing
• Ottorrhea : clean the blood and no
syringing
* Strict attention for the underlying brain
damage.
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BRAIN INJURY
• Types :
1. Concussion
2. Contusion
3. Laceration
4. Compression by post-traumatic intracranial
haemorrhage
 Extradural hematoma
 Subdural hematoma
 Intracerebral hemorrhage(mostly not
amenable for surgical management)
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BRAIN CONCUSSION
• Is a transient effect of a mild head injury
which causes slight neuronal damage
• No physical damage.
• There is temporary physiological paralysis
of the nervous system.
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Clinical features of brain
concussion
• Hx. of trauma to the head
• Short period of post-traumatic retrograde
amnesia
• By clinical examin. : Signs of trauma on the
head can be detected.
• The recovery may be complete, even though,
some can develop complications.
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BRAIN CONTUSION
• In this type of post-traumatic brain damage,
part of the brain is bruised
• The period of post-traumatic retrograde
amnesia is longer than of brain
concussion(from hrs. to many days or
months)
• It is caused by acceleration(direct trauma –
coup/ contra-coup) or deceleration.
• The recovery is longer than in brain
concussion(many days)
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23.
Clinical features of brain
contusion
 Headache
 Vomiting
 Vertigos
 Convulsions(generalized / localized)
 Restlessness
 Osteo-ligament hyperreflexia
 Spastic hemi paralysis
 Pupilary alterations(dilatation / constriction)can be
presented, making it difficult to differentiate clinically
from a brain compression by hematoma
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24.
BRAIN LACERATION
• Is a more serious pathologic state.
• Results from direct trauma associated with skull
fracture or brain disruption.
• There is tear of the brain.
• If not well treated, the hemorrhage from the torn
vessels and edema of the damaged brain produce
compression and damage to the vital centers in the
brain stem and medulla, causing death.
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25.
Clinical features of brain
laceration
• Hx. of trauma to the head
• Restlessness
• By clinical examination the following data should
be looked for :
• Level of consciousness
• Signs of paralysis of cranial nerves
• Spasticity or paralysis of the limbs
• State of the reflexes
• State of the pupils
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26.
Extradural
haemorrhage(haematoma)
• Is usually due to middle
meningeal vessel lesion by
fractured skull.
• Is also called epidural
haematoma.
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Clinical features of extradural post-traumatic
haemorrhage
• Hx. of head injury
• Short period of unconsciousness or gradual deterioration of the level of
consciousness
• Bruising / edema of the scalp on the affected side
• Development of focal paralytic signs such as:
– Weakness / spasticity of the contra lateral upper or lower
extremity.
– Contra lateral extensor plantar response exaggeration
– Dilated and fixed pupila on the lesioned side due to
compression of the oculomotor nerve by herniated brain
through the tentorium.
– Tachycardia initially, which progresses to bradycardia
– High Bp due to increased intracranial pressure
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28.
Subdural post-traumatic hematoma
• Is due to haemorrhage into the subdural space
from lacerated veins connecting the cerebral
cortex and the venous sinuses.
• According to its time of manifestation it can be :
• Acute (usually is associated with brain
laceration and severe injury)
and appears in 24hrs. after trauma
• Sub-acute (appears in 7-10 days after
the injury)
• Chronic (appears from several weeks
– months) 28

29.
Clinical features of post-traumatic
subdural hematoma
I. If acute : same as extradural hematoma
II. If sub-acute: gradual onset of symptoms & signs
of brain compression with progressive
deterioration of level of consciousness.
III. If chronic:
 Hx. of slight head injury weeks or months
before
 Usually it is due to tearing of the cerebral
veins without damage to the brain substance
 Persistent headache
 Increasing drowsiness
 Confusion
 Mild hemi paresis
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30.
Diagnostic investigations for head injury in general
1. Skull x-ray in pts. With:
 Loss of consciousness
 Scalp laceration / contusion
 Palpable depression / fracture
 Focal neurological signs
2. Ct-scan / MRI in pts. with:
 Presence of depressed skull fracture
 Focal neurological signs
 Deterioration of level of consciousness
 Comatose pts.
 Non-regaining of consciousness despite adequate resuscitating
measures
 Post-traumatic seizures.
3. EEG(electro-encephalography):in chronic subdural haematoma
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31.
NICE guidelines for computerised tomography (CT)
in head injury
• ■ Glasgow Coma Score (GCS) < 13 at any point
• ■ GCS 13 or 14 at 2 hours
• ■ Focal neurological deficit
• ■ Suspected open, depressed or basal skull fracture
• ■ Seizure
• ■ Vomiting > one episode
• Urgent CT - scan if none of the above but:
• ■ Age > 65
• ■ Coagulopathy (e.g. on warfarin)
• ■ Dangerous mechanism of injury (CT within 8
hours)
• ■ Antegrade amnesia > 30 min (CT within 8 hours)
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Management of head injury in
general
• Is based on :
I. Initial assessment
II. Resuscitation
III. Neurological assessment
IV. Secondary survey
V. Medical Rx.
VI. Surgical Rx.
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Initial assessment of pts. with head
injury
• It includes assessment of A B C D E where :
1. A : airway(with cervical spine control)
2. B : breathing(RR & effort)
3. C : circulation(BP, pulse, hemorrhage
control)
4. D : disability (neurological status):
 A : alert(minor head injury)
 V : vocal(moderate head injury)
 P : pain (severe head injury)
 U : unresponsive (very severe head
injury)
5. E : exposure 33

34.
Resuscitation of pts. with
head injury
• Addresses the immediate concerns of airway,
breathing and circulation .
• It is based on:
– Cleaning the airway
– Mouth gag to prevent tongue falling
backwards
– Intubation & O2 (if needed, to prevent hypoxia
and cerebral edema)
– Monitor pulse & BP
– Install iv line with crystalloids(RL / N/s)
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35.
Neurological Assessment of pts. with head
injury
includes :
■ Glasgow Coma Score
■ Pupil size and response
■ Lateralising signs
■ Signs of base of skull fracture
• Bilateral periorbital oedaema (raccoon eyes)
• Battle’s sign (bruising over mastoid)
• Cerebrospinal fluid rhinorrhoea or otorrhoea
• Haemotympanum or bleeding from ear
■ Full neurological examination: tone, power, sensation,
reflexes
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36.
Assessment of level of
consciousness(Glasgow Coma Score)
• The severity of head injuries is most commonly
classified by the initial post resuscitation Glasgow
coma score (GCS) which generates a numerical
summed score for eye, motor, and verbal abilities
(responses).
• Is calculated out of 15 points
• It includes :
– Eyes opening
– Best verbal response
– Best motor response
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37.
Glasgow Coma Score (GCS)
I. Eyes open:
 Spontaneously: 4
 To speech: 3
 To pain: 2
 None: 1
II. Best verbal response:
 Oriented: 5
 Confused: 4
 Inappropriate words: 3
 Incomprehensible sounds: 2
 None: 1
III. Best motor response:
 Obeys commands: 6
 Localizes pain: 5
 Withdrawal to pain: 4
 Flexion to pain: 3
 Extension to pain: 2(severe damage with increased ICP)
 None: 1 37

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Contin. Of Glasgow coma scale
• Total score is : 15
• Minimum score is: 3
• Any pt. who has GCS of 7 or less is said to be in coma.
• Traditionally, a score of 13-15 indicates mild injury, a score
of 9-12 indicates moderate injury, and a score of 8 or less
indicates severe injury. In the last few years, however, some
studies have included those patients with scores of 13 in the
moderate category, while only those patients with scores
of 14 or 15 have been included as mild..
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39.
Secondary survey of the pt with
head injury
• Is called, also, general assessment of the pt.
• It includes:
Exposure of the pt. to do clinical exam. In
all aspects(sides) to R/o associated:
Intra-abdom. Injury
Intra-thoracic collection
Long bones fractures etc.
Taking hx. of circumstances led to injury
Allergies
Medications and drugs taken
Past hx. of illness(DM., epilepsy)
Last meal taken
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40.
Medical Rx. of pts. with head injury
• Aim : to prevent secondary changes and to optimize
recovery from the primary injury.
• Is based on :
Careful observation and monitoring of v/s.
 Careful monitoring of the neurological status
Adequate ventilation
Control of the rise in intra-cranial pressure using:
Manitol / lasix
Hyperventilation
Putting the pt. In 300 of head- up to facilitate venous
drainage from the head and to lower ICP.
Catheterizations
Positional changes
TAT.(If open wounds) and iv. Antibiotics 40

41.
Surgical Rx. of pts. with head
injury
• Is indicated in:
1. Head injury with clear-cut intracranial
collections (hematomas): burrhole &
evacuation
2. Head injury with strong suspicion of intra-
cranial collections compressing the brain
tissue: exploratory burrhole(holes)
3. Depressed skull fractures: elevation
4. continuos CSF leakage with failed
conservative Rx. after head injury: repair of
the teared dura
5. Post-traumatic intracranial abscess 41

42.
Complications of head
injury
1. Epilepsy
2. CSF leakage
3. Ch. subdural haematoma
4. Infections:
• Meningitis
• Pott's puffy tumor(infected
hematoma / skull osteomylities)
• Subdural empyema
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43.
BIBLIOGRAPHY
1. MANIPAL: MANUAL OF SURGERY,1ST.
EDITION, 2000
2. BAILEY & LOVE’S:SHORT PRACTICE
OF SURGERY,22ND. EDITION, 1997 or
25th. edition
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THE END
THANK U VERY
MUCH !!!
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