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Head injuries

Presentation made at GMCTH, Pokhara during the period of internship!

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Head injuries

  1. 1. Head Injuries Dr Sajal Twanabasu Intern GMCTH
  2. 2. Definition  Any injury that results in the trauma to the scalp, skull or brain.  Traumatic brain injury (TBI) encompasses a broad range of pathologic injuries to the brain of varying clinical severity that result from head trauma.  Head injury and traumatic brain injury are often used interchangeably
  3. 3. Etiology  Motor Vehicle Crashes- 44%  Falls - 26%  Other/Unknown - 13%  Non-Firearm Assaults - 9%  Firearms - 8%
  4. 4. Pathophysiology  On the basis of mechanism of production, head injury can be classified as:  Impact injuries: It results from an object striking the head or the head striking an object.  It includes: Scalp injuries Skull fracture Cerebral contusion and laceration Epidural haematoma
  5. 5.  Acceleration and deceleration injuries: It results essentially as a result of differential movement between skull and cranial content.  It includes: Diffuse axonal injury Sub-dural hematoma
  6. 6. 666 Coup injury Contracoup injury Coup injury:  It occurs at the site of the impact to the head and are produced by compression of brain due to inward movement of the bone Countre-coup:  Injury occurs directly opposite to the point of impact and are most common in frontal and temporal lobe.  Produced by the head in motion impacting on a stationary object
  7. 7. Consequences of head injury Injury to the scalp:  There can be scalp contusion, abrasion and/or lacerations  Tremendous vascularity of the scalp can cause profuse bleeding  Osteomyelitis may develop after closed injury following infections of sub-periosteal blood clot referred as Pott’s Puffy tumour
  8. 8. Skull Fracture Simple linear fracture:  It is the break in the bone that transverses the full thickness of the skull from the outer to inner table  No clinical significance  Fracture that transverses a suture line or involves a venous sinus groove or vascular groove should be dealt cautiously
  9. 9. Depressed Skull Fracture  Results from blunt trauma  Inner table extensively affected than the outer table  High risk of increased pressure on the brain or hemorrhage to the brain that crushes the delicate tissue
  10. 10.  Compound depressed fracture is in contact with the outside environment increasing the risk of contamination and infection  Complex depressed fracture tears the duramater increasing the risk of cortical damage and epilepsy
  11. 11. Base of skull fracture Anterior cranial fossa fracture:  It may lead to subconjunctival haematoma, extending to posterior limit of sclera, epistaxis, CSF rhinorrhea Middle cranial fossa fracture:  It involving the petrous temporal bone presents with CSF otorrhoea, haemotympanium, ossicular disruption, Battle sign, 7th and 8th cranial nerve palsy.
  12. 12. Brain injury Primary brain injury:  Injury caused at the time of impact  Irreversible Secondary brain injury  Subsequent or progressive brain damage arising from events developing as a result of primary brain injury
  13. 13. Primary braininjury Secondarybraininjury Concussion Intracranial haematoma Cortical laceration/contusion Cerebral oedema Diffuse axonal injury Ischaemia Bone fragmentation Infection Metabolic or endocrine disturbances
  14. 14. Diffuse Axonal Injury  Results from mechanical shearing at grey- white interface due to severe acceleration and deceleration force  No obvious structural damage  Severity may range from mild damage with confusion to coma and even death  Major cause of unconsciousness and persistent vegetative state after head trauma
  15. 15. Cerebral Concussion  It is the condition of temporary dysfunction of brain without any structural damage following head injury  It is manifested as: Transient loss of consciousness Transient loss of memory Autonomic dysfunction like bradycardia, hypotension and sweating
  16. 16. Cerebral Contusion  It is more severe degree of brain injury manifested by areas of hemorrhage in the brain parenchyma but without surface laceration  Neurological deficit which persists more than 24 hour  Associated cerebral edema and defects in the blood brain barrier
  17. 17. Cerebral laceration  Severe degree of brain injury associated with a breach in the surface parenchyma  Tearing of brain surface may be due to skull fracture or due to shearing forces  Focal neurological defecit may be present
  18. 18. Extradural haematoma  Collection of blood between the cranial bones and duramater  It is associated with the fracture of temporo-parietal region  Commonest vessel: Middle meningeal artery  Lucid interval may be present  Confusion, irritability, drowsiness, hemiparesis to the same side of injury  Hutchinson’s pupils  Features of raised ICP: hypertension, bradycardia, vomiting
  19. 19.  CT scan: Biconvex lesion  It is the surgical emergency  Craniotomy and evacuation of clot is done.
  20. 20. Sub Dural Haematoma  Collection of blood between brain and duramater  Common intracranial mass lesion resulting from trauma Acute: <3 days Sub-acute: 4-21 days Chronic: >21 days
  21. 21. Sub Dural Haemotama  Results from torn bridging vein or injury to the cortical artery  Haematoma extensive and diffuse  No lucid interval  Loss of consciousness occurs immediately after trauma and is progressive  Features of raised ICP and focal neurological defecits  CT Scan: Concavo-convex lesion  T/t: surgical decompression by craniotomy  Antibiotics
  22. 22. Cerebral Herniation  Increased ICP or presence of intracranial mass may predispose to cerebral herniation.  Herniation of contents of supratentorial compartment through the tentorial hiatus  Herniation of the contents of the infraintentorial compartment through the foramen magnum
  23. 23. Brain swelling  It follows significant head injury  Occurs due to active hyperaemia and edema Infection, Seizure, Hydrocephalus
  24. 24. Approach to Head Trauma  Detailed history should be sought in all cases of head trauma.  If the patient is unconscious which is usually the condition, history should be obtained from the attendant.  While one care provider is taking history, resuscitation should be carried out simultaneously by other care provider.
  25. 25. Ask about:  Type of accident: ?RTA, ?fall from height ?acceleration/deceleration injury during driving a motor car  Level of consciousness: ?Unconscious, ?semiconscious  If unconscious: duration of unconsciousness, ?immediately after trauma ?lucid interval  Post traumatic amnesia
  26. 26. Ask about:  Vomiting: ?blood in vomitus ?persistent vomiting ?sign of recovery from cerebral concussion  Epileptic fits or seizure: Its nature may give clue to localization of the site of trauma  Swelling and pain in the head  Other complaints: ?bleeding or watery discharge from ear, nose and mouth
  27. 27. Ask about:  Past history: ?fits or similar head injury in the past ?Hypertension ?DM ?Renal diseases  Personal history: ?unconsciousness due to other cause (alcohol, opium poisoning, diabetic coma)  Family history: History of diabetes, HTN, epilepsy in the family
  28. 28. Immediate management  Initial assessment of head injuries must follow advanced trauma and life support. (ALTS)  It includes: Maintenance of airway along with cervical spine control Cervical spine immobilized in neutral position using neck brace, sand bags, forehead tape Suction of airway to clear blood, vomitus Chin lift, jaw thrust Oropharyngeal airway ET tube, tracheostomy as necessary
  29. 29.  Maintenance of breathing  Assessment of circulation and control of haemorrhage  Establish iv access with two large bore iv cannulas IV infusion of NS (Avoid 5% Dextrose as it may precipitate cerebral edema)  Assessment of dysfunction of CNS  Exposure in a controlled environment Remove all clothes and look for any obvious external injury
  30. 30. Physical examination  Pulse and blood pressure: Pulse will be rapid, thready with low BP in case of cerebral concussion Pulse becomes slow and bounding with high BP in case of cerebral irritation Rapid pulse in deeply unconscious heralds impeding death
  31. 31.  Temperature: In cerebral concussion, contusion temperature may remain subnormal With appearance of cerebral compression, temperature may rise upto 100˚F Victor Horsley’s sign
  32. 32. Physical examination  Head: Patient’s head must be shaved fully Look thoroughly for any fracture of the skull, hematoma and assess the type of fracture Site of injury often gives clue towards the diagnosis.  Position of the patient  Eyes: Is there any evidence of haemorrhage in and around the eyes? The condition of pupil
  33. 33. Neurological assessment Neurological assessment can be done by using Glasgow coma scale.
  34. 34.  Minor head injury: GCS 15 with no loss of consciousness (LOC)  Mild head injury: GCS 14 or 15 with LOC  Moderate head injury: GCS 9–13  Severe head injury: GCS 3–8.
  35. 35.  Presence of neurological deficits: Check for power, tone, superficial and deep tendon reflexes  Rigidity of the neck: May be present in the case of subarachnoid hemorrhage, fracture dislocation of cervical spine  Cranial nerve examination Cranial nerve should be examined one after another Of these most important is the third nerve  Check for any other CNS manisfestation: ?Ataxia ?nystagmus
  36. 36. General Examination Examine  Chest for the fracture of the ribs, surgical emphysema  Spine, pelvis and limbs for the presence of fracture  Exclude abdomen for rupture of any hollow viscus, internal haemorrhage form injury to any solid viscus eg: liver, spleen
  37. 37. Management:  Place a Nasogastric tube to decompress the stomach and reduce the risk of vomiting as aspiration  Avoid NG tube for the patients with facial injuries as the tube could enter the brain through bony fracture  Insert an dwelling urinary catheter for hourly urine output monitoring  Avoid insertion if urethral injury suspected
  38. 38. Treatment of raised ICP  IV Mannitol  IV furosemide  Reverse Trendelenburg if no counter indications like hypovolaemia, spine injury  If significant agitation and if hypoxia, hypovolaemia or pain is excluded as the cause of agitation: give IV Midazolam  Analgesics for the pain management  Phenytoin or phenobarbitone for post traumatic seizure
  39. 39. Monitor  Blood pressure  Heart rate  Respiratory rate  Spo2  ECG  Blood samples for serum electrolyte Arterial blood gas hyper/ hypoglycaemia
  40. 40. Special investigations!!!! Definitive treatment!!!!
  41. 41. 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
  42. 42. Rehabilitation Physiotherapy Occupational Therapy Speech and Language Therapy Psychologists/Psychiatrists
  43. 43. References  SHORT PRACTICE of SURGERY Bailey & Love’s 25th Edition  SRB Manual Of Surgery  Death & Deduction Forensic Medicine  A Manual On Clinical Surgery