This document defines and describes head injuries, including types of injuries such as closed and open head injuries. It discusses mechanisms of primary and secondary brain injuries. It also outlines signs and symptoms, diagnosis including imaging tests, and treatment for both the acute and chronic stages. Treatment in the acute stage focuses on the ABCDE approach, increasing ICP management, and surgery if needed. Long term complications and prevention methods are also mentioned.

2. CROSS-SECTION

3. HEAD INJURY - DEFINITION
• Any injury that results
in trauma to the SCALP,
SKULL or BRAIN.
• TRAUMATIC BRAIN
INJURY and HEAD
INJURY are often used
interchangeably.

4. HEAD INJURY - TYPES
OPEN HEAD INJURY:
There is penetration to the skull.
CLOSED HEAD INJURY
There is NO penetration to the skull.

5. COUP-CONTRECOUP INJURIES
• Damage may occur
directly under the site
of impact (COUP), or it
may occur on the side
opposite the impact
(CONTRECOUP).

6. HEAD INJURY - MECHANISMS
PRIMARY INTRACRANIAL INJURY
• It is the initial neuronal
damage that occurs
IMMEDIATELY as result of
trauma.
SECONDARY INTRACRANIAL
INJURY
• Secondary injuries are the
result of the
neurophysiological and
anatomic changes, which
occur from MINUTES to
DAYS after the original
trauma.

7. HEAD INJURY - MECHANISMS
PRIMARY INTRACRANIAL INJURY
• Cerebral Laceration
• Cerebral Contusion
• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid Hematoma
• Intracerebral Hematoma
• Diffuse Axonal Injury
SECONDARY INTRACRANIAL
INJURY
• Edema
• Impaired Metabolism
• Altered Cerebral Blood Flow
• Free Radical Formation
• Excitotoxicity

8. SCALP INJURIES
LACERATIONS SUBGALEAL HEMATOMA

9. SKULL INJURIES
CLOSED FRACTURES
• A closed fracture has a
significant chance of
associated intracranial
haematoma.
OPEN FRACTURES
• Open fractures have
potential for serious
infection.
• Any foreign matter impaled
in the skull should be left in
place for removal by the
neurosurgeons.
• Cover it lightly with a sterile
dressing that has been
moistened with a sterile
saline.

10. SKULL INJURIES
CT SCAN OT

11. SKULL INJURIES
DEPRESSED FRACTURES/COMPOUND
DEPRESSED FRACTURES
NON-DEPRESSED LINEAL
FRACTURES

12. SKULL INJURIES - BASILAR SKULL
FRACTURE

13. SKULL INJURIES - BASILAR SKULL
FRACTURE
RACCOON EYE

14. SKULL INJURIES - BASILAR SKULL
FRACTURE
BATTLE’S SIGN

15. SKULL INJURIES - BASILAR SKULL
FRACTURE
BLEEDING FROM THE EAR CANAL
CSF LEAKAGE FROM THE EAR OR
NOSE

16. BRAIN INJURIES
DIFFUSE
• Concussion
• Diffuse Axonal Injury
FOCAL
• Contusion
• Brain Lacerations
• Epidural haematoma
• Subdural haematoma
• Subarachnoid haemorrhage
• Parenchymal haematoma

17. HEAD INJURY (DIFFUSE) -
CONCUSSION
• Brain injury that does
not result in any
evidence of structural
alteration.
• Return of consciousness
moments or minutes
after impact.
• There may be brief
confusion,
disorientation,
headache, dizziness,
amnesia.
• CT scan is normal.

18. HEAD INJURY (DIFFUSE) - DIFFUSE
AXONAL INJURY

19. BRAIN CONTUSION

20. EPIDURAL HEMATOMA
SCHEMATIC CT SCAN

21. SUBDURAL HEMATOMA
SCHEMATIC CT SCAN

22. SUBARACHNOID HEMATOMA
SCHEMATIC CT SCAN

23. INTRACEREBRAL HEMATOMA
SCHEMATIC CT SCAN

24. HEMATOMAS

25. CEREBRAL EDEMA
NORMAL CT SCAN CEREBRAL EDEMA

26. SIGNS
A sign of ↑ICP
(INTRACRANIAL PRESSURE)
CUSHING REFLEX
↑ Blood Pressure
↓ Pulse Rate
↓ Respiratory Rate

27. SIGNS
• A UNILATERAL , FIXED
DILATED PUPIL indicates
neurologic deterioration
may be secondary to
hypoxia, hypovolaemia or
hypoglycaemia, due to
↑ICP, and compression of
the 3rd Cranial Nerve
(OCULOMOTOR NERVE).
DILATED PUPIL

28. SIGNS

29. SIGNS
DECORTICATE POSTURING
• Arms Flexed
• Arms bent inward on the
chest
• Hands clenched into fists
• Legs Extended
• Feet turned Inward
• Score of 3 in the Motor
section of the Glasgow
Coma Scale

30. SIGNS
DECEREBRATE POSTURING
• Head is arched back
• Arms Extended by the sides
• Legs Extended
• Patient is rigid with the
teeth clenched.
• Score of 2 in the Motor
section of the Glasgow
Coma Scale

31. SYMPTOMS
• Confusion/Irritibility
• Drowsiness
• Dizziness
• Nausea & Vomiting
• Amnesia
• Speech/Swallowing
Difficulty
• CSF Leakage
• Ear Bleeding
• Numbness/Paralysis
• Coma

32. SYMPTOMS

33. SYMPTOMS

34. DIAGNOSIS
HISTORY
PHYSICAL EXAMINATION
HEAD & NEUROLOGIC EXAM
CT SCAN

35. DIAGNOSIS - HISTORY
PATIENT
PEOPLE

36. DIAGNOSIS - PHYSICAL EXAMINATION
ABCDE
• A = AIRWAY
• B = BREATHING
• C = CIRCULATION
• D = DISABILITY
• E = EXPOSURE
• GLASGOW COMA SCALE
(GCS)
• SYSTEMIC EXAMINATION

37. GLASGOW COMA SCALE
MINIMUM=3/15 MAXIMUM=15/15 INTUBATION <8/15

38. GLASGOW COMA SCALE (GCS)
SEVERITY SCORE
13-15
9-12
3-8
MILD
MODERATE
SEVERE

39. GLASGOW COMA SCALE (GCS)
SEVERITY LOSS OF CONSCIOUSNESS
0-30 mins
>30 mins to <24 hrs
>24 hrs
MILD
MODERATE
SEVERE

40. DIAGNOSIS - HEAD AND NEUROLOGIC
EXAM
HEAD EXAM
• Hematoma
• Contusion
• Fracture e.g. Basilar Skull
Fracture
• Laceration
NEUROLOGIC EXAM
• Cranial Nerves
• Muscle Tone
• Muscle Power
• Sensations
• Walking Gait

41. DIAGNOSIS - OTHERS
X-RAYS / MRI
ANGIOGRAPHY
EEG
TRANSCRANIAL DOPPLER

42. TREATMENT
ACUTE STAGE
CHRONIC STAGE

43. TREATMENT - ACUTE STAGE
CERVICAL IMMOBILIZATION
• Philadelphia Collar

44. TREATMENT - ACUTE STAGE (AIRWAY)
ENDOTRACHEAL INTUBATION
• If intubation is impossible:
Laryngeal Mask or
Cricothyrotomy are
indicated.
SIGNS OF ↓OXYGEN
• Respiratory rate < 10 or >40
bpm.
• S02 <90% breathing oxygen
or <85% breathing air
• Hypercarbia that implies
pH<7.2
• Hypoxia Pa02<50 mm Hg

45. TREATMENT - ACUTE STAGE (AIRWAY)
LARYNGEAL MASK

46. TREATMENT - ACUTE STAGE (AIRWAY)
CRICOTHYROTOMY

47. TREATMENT - ACUTE STAGE (AIRWAY)
ENDOTRACHEAL INTUBATION
• Rapid sequence intubation
is performed, using sedative
agents and muscle
relaxants.
MECHANICAL VENTILATION
STANDARD PARAMETERS
• Tidal Volume: 8-10 ml/kg
• Rate: 12-15 bpm
• Pressure: 15-20 cm H20
• Fi02: 1

48. TREATMENT - ACUTE STAGE
(BREATHING)
• Start high-flow oxygen
administration (10-12 l/min)

49. TREATMENT - ACUTE STAGE
(CIRCULATION)
• Establish IV access with
two large-bore(14- or16
gauge) IV cannulas.
• IV infusion of Normal
Saline (NS).
• IV Norepinephrine
• AVOID giving 5% Dextrose
unless hypoglycaemia is
present.
• Dextrose ↑cerebral
oedema
• If BP is normal AVOID
giving excessive volumes
of fluids that may
↑cerebral oedema.

50. TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP
• IV Mannitol (Osmotic
Diuretic)
• IV Furosemide
• Hyperventilation

51. TREATMENT - ACUTE STAGE
(DISABILITY)
TREATMENT FOR ↑ICP
• If there are no counter-
indications (hypovolaemia,
spine injury) place the
patient in
“Reverse-Trendelenburg”
position
REVERSE-TRENDELENBURG

52. TREATMENT - ACUTE STAGE
(DISABILITY)
• If significant agitation and after excluding
hypoxia, hypovolaemia or pain, as the cause of
agitation: IV Midazolam

53. TREATMENT - ACUTE STAGE
(EXPOSURE)
• AVOID ↓Body
Temperature
• ↑Body Temperature:
Cooling measures and
IV Paracetamol
• Pain medication: IV
Fentanyl
• Anti-Emetics
• Post-Traumatic
Seizures: IV Diazepam

54. TREATMENT - ACUTE STAGE
(PARAMETERS)
MONITOR
• Blood Pressure
• Heart Rate
• Respiratory Rate
• S02, Etc02
• ECG
BLOOD SAMPLES
• Serum Electrolytes
• Arterial Blood Gas
• Hyper/Hypoglycaemia

55. TREATMENT - ACUTE STAGE
(CATHETERIZATION)
NASOGASTRIC TUBE
• Place a Nasogastric tube
(NG Tube) to decompress
the stomach and reduce the
risk of vomiting as
aspiration.
• AVOID NG Tube for patients
with facial injuries. The tube
could enter the brain
through a bony fracture.

56. TREATMENT - ACUTE STAGE
(CATHETERIZATION)
URINARY CATHETER
• Insert an indwelling urinary
catheter for hourly urine
output monitoring.
• AVOID insertion if injury is
suspected to the urethra.

57. TREATMENT - ACUTE STAGE
(SURGERY)
DECOMPRESSIVE CRANIOTOMY

58. TREATMENT - CHRONIC STAGE
REHABILITATION
Physiotherapy
Neurologists
Occupational Therapy
Speech and Language Therapy
Psychologists/Psychiatrists

59. 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

60. PREVENTION
HELMETS
SEAT BELTS
FALLS IN THE ELDERLY
RESTRICTING ALCOHOL USE