HEAD INJURY

1. WELCOME

2. HEAD INJURY
CHAIRPERSON: PRESENTED BY:
PROFESSOR DR.A.S.M. LOKMAN HOSSAIN CHOWDHURY DR.JAFOR EKBAL
DEPARTMENTAL HEAD,PAEDIATRIC SURGERY PHASE-A,RESIDENT
MMCH. PAEDIATRIC SURGERY
MMCH.

3. CONTENTS
• Introduction
• Defination
• Mechanism of head injury
• Different type of head injury
• Assessment and investigation
• Management
• Reference
• conclution

4. WHAT IS HEAD INJURY
Trauma to scalp,skull,brain
Injury may be bump on the skull or serious brain injury by external force

5. EPIDEMIOLOGY
• Leading cause of death and disability
• Accounts for 3-4% of emergency department attendances
• 1500 cases per 100 000 population per year in UK

6. MECHANISM OF HEAD INJURY
1. Coup injuries :Direct impact against calvarium and brain
2. Countercoup injuries :Injuries on the side opposite to the impact
3. Penetrating injuries (gun shot)

7. CONTINUE…..

8. CAUSES OF HEAD INJURY
• RTA
• Fall from height
• Physical assault
• Accident at home
• Playing sports
• Crush injury
• Firearm

9. DIFFERENT TYPE OF INJURY
• Scalp injury:
* abrasion
* laceration
* contusion
* subgalial hematoma
• Skull injury:
* linear skull fracture
*depressed fracture
* basilar fracture

10. CONTINUE……..
• Brain injury:
*concussion
* contusion
*diffuse axonal injury
* intracranial hemorrhage(extradural,subdural,intracerebral)

11. SKULL FRACTURES
• Linear fracture :
* Low energy blunt trauma over a wide area of skull
* thine line on x-ray.
* do not require treatment.
• Depressed fractures:
* high energy force over a small area of skull.
* may be open or closed.
* indication for surgery are cosmesis.
* intacranial haematoma requiring evacuation.

12. SCALP INJURY

13. DEPRESSED SKULL FRACTURE

14. CONTINUE……..
• Basilar skull fracture :
* linear fracture at base of the skull(frontal,temporal).
* clinical sign are bleeding or CSF leak through ear(otorrhoea) or nose(rhinorrhoea)
* bruising behind the ear(battle sign) or around the eyes(panda sign).
* CSF leak will generally resolve spontaneously but persistent leak result meningitis
so may be repaired.
*blind NG tube placement is contraindicated

15. CONTINUE……

16. CONTINUE……

17. BRAIN INJURY
• Concussion:
*Alteration of consciousness due to closed head injury
*due to trauma to brain from impact or sudden momentum
*no imaging abnormality
*may be lethargic, forgetful,slow to interact,gait disturbance,incoordination
• Contusion:
*bruise in the brain
*due to vascular and tissue damage
*rarely require surgical intervention

18. CONTINUE……..
• Diffuse axonal injury:
*form of primary brain injury
*due to high energy accidents
*patient may be comatose
*strictly a pathologic diagnosis made at postmortem
*CT often appears normal

19. BRAIN INJURY
• Extradural haematoma:
*hematoma forms between the skull and dura matter
*due to fracture temporal bone,rupture artery(middle meningeal
artery),vein or venous sinus
*loss of consciousness with lucid interval,ipsilateral pupil dilatation
*on CT hematoma appears lentiform(lens shaped or biconvex)
*need urgent transfer to the accessible neurosurgical facility
*prognosis for promptly evacuated extradural haematoma is excellent

20. CONTINUE…..

21. CONTINUE…….
• Subdural haematoma :
*haematoma between dura matter and subarachnoid space
* high energy injury mechanism result in rupture of cortical vein with
primary brain injury
*developing sign of raised ICP
*Rquire promt evacuation by craniotomy
*mortality rate high

22. CONTINUE…..

23. CONTINUE…….
• Intracerebral haemorrhage :
*haemorrhage within the cerebral parenchyma
*due to secondary to lacerations or contusions of brain,
injury to larger,deeper cerebral vessels
• Subarachnoid haemorrhage :
*caused by laceration of the superficial microvesels in the
subarachnoid space
*if blood product obstruct arachnoid villi it may causes
communicating hydrocephalus

24. GLASGOW COMA SCALE(PAEDIATRIC)
Score Eye opening Verbal response Grimace response Motor response
1 None None None None
2 To pain Occational whimper/moan Mild to pain Extends to pain
3 To voice Inappropriate cry Vigorous to pain Flex to pain
4 Spontaneous Decreased verbal/irritable cry Less than usual face
movement
Withdraws
5 Alert babbles/word as normal Spontaneous face movement Localises pain
6 Obeys commands

25. INTERPRETATION OF GCS
Minor head injury GCS 15 with no loss of consciusness
Mild head injury GCS 14 or15 with LOC
Moderate head injury GCS 9-13
Severe head injury GCS 3-8

26. INDICATIONS OF REFERRAL TO HOSPITAL OF
CHILDREN
1. GCS<15 at any time since head injury
2. Any loss of consciousness as a result of injury
3. Any focal neurological deficit
4. Any seizure since injury
5. Persistent headache since injury
6. Suspician of skull fracture or penetrating head injury
7. CSF leak from the ear or nose
8. Multiple injury in association with head injury
9. Suspician of NAI
10. Amnesia before or after injury

27. INDICATION FOR CT SCAN AFTER HEAD INJURY
1. GCS<13 at any point since injury
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture
4. Post traumatic seizure
5. Focal neurological deficit
6. Persistent vomiting
7. Amnesia greater than 5 min of events before impact

28. INDICATIONS OF SUSPECTED NON ACCIDENTAL HEAD INJURY IN
CHILDREN
• Suspicious and inconsistent story
• History of previous injuries
• Multiple cutaneous bruise of different age
• Bilateral retinal haemorrhage
• Acute subdural haemorrhage and brain swelling on CT scan
• Bilateral skull fracture
• Old fracture of long bones and ribs
• Evidence of malnourishment
• Subdued behaviour

29. ASSESSMENT AND DIAGNOSTIC EVALUATION
• Details history about injury
• Assessment
• CT scan
• X-ray
• EEG
• ABG
• MRI
• Cerebral angiography

30. MANAGEMENT
• Medical therapies:
*Restoration of normal BP
*Intubation and ventilation
*Elevation of head of bed
*Keep head in neutral position
*Sedation and muscular paralysis
*normal fluid, electrolyte status,blood glucose,body temperature
*Ventricular CSF drainage by ventricular catheter
*Mannitol
*High dose barbiturate

31. CONTINUE……
• Surgical management :
*Craniotomy
*Vp shunting
*Elevation of fragment in depressed skull fracture
*Repair of CSF leakase

32. SEQUELE OF HEAD INJURIES IN CHILDREN
• Chronic headache
• Mental retardation
• Growth failure
• Learning disability
• Memory loss
• Epilepsy
• CSF leak

33. PREVENTION AND HEALTH EDUCATION
• Avoid driving after alcohol conjumption
• Use seat belt during driving
• Children less than 12 years should be restrained in an age appropriate system in back side
• Motorcyclist,bicllists should wear helmets
• Advice athlets to use protect device

34. REFERENCE
• Bailey and love`s 27th edition
• Jones` clinical Paediatric surgery 7th edition

35. THANK YOU