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
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. 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. 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. 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. 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. 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. 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. 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.
13. 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
15. 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
16.
17. 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
18. 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
19. 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
20. 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
21. CT scan: Biconvex lesion
It is the surgical
emergency
Craniotomy and
evacuation of clot is
done.
22. 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
23. 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
24. 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
25. Brain swelling
It follows significant head
injury
Occurs due to active
hyperaemia and edema
Infection, Seizure, Hydrocephalus
26. 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.
27. 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
28. 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
29. 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
30. 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
31. 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
32. 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
33. Temperature:
In cerebral concussion, contusion temperature may remain
subnormal
With appearance of cerebral compression, temperature
may rise upto 100˚F
Victor Horsley’s sign
34. 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
36. 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.
37. 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
38. 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
39. 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
40. 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
45. References
SHORT PRACTICE of SURGERY Bailey & Love’s 25th Edition
SRB Manual Of Surgery
Death & Deduction Forensic Medicine
A Manual On Clinical Surgery