This document discusses head injuries and their management. It covers various types of head injuries like scalp lacerations, skull fractures, and different types of intracranial bleeding. Assessment involves the Glasgow Coma Scale and other scales. Management depends on the type of injury and may include wound closure, observation, surgery to repair fractures or evacuate hematomas. The goal is to prevent secondary brain damage from low blood pressure, hypoxia, swelling, and infections.

1. HEAD INJURIES
• BY DR MOHAMMED HANEEF

2. • Common major trauma
• 4 million people experience head trauma
annually
• Severe head injury is most frequent cause of trauma death
• GSW to cranium: 75-80% mortality
• At Risk population
• Males 15-24
• Infants
• Young Children
• Elderly
Head Injuries

3. Introduction
The head is very vulnerable to injury, often with severe
consequences.
It is particularly susceptible to acceleration/deceleration and
rotational forces because it is heavy in relation to its size (3-6 kg,
avg 4.5 kg or 10 lb), is freely mobile in 3 dimensions and
occupies a relatively unstable position, being secured only by
the neck muscles and ligaments.

4. 4
Initial clinical evaluation
Rapid assessment of patients neurological disability
can be made on 4 point AVPU SCALE
1. Responds appropriately-Awake
2. Responds to Verbal stimuli
3. Responds to Painful stimuli
4. Does not respond -Unconscious
Coupled with an assessment of pupil reaction allows
rapid assessment of degree of head injury

5. Head Injuries
• ABC (PRIMARY SURVEY)
• C – consciousness
• R – respiration
• A - Trauma
• N – Neck
• Cervical/Carotid Injury
• E- Eyes
• Pupils
• Extra ocular muscles
• Corneal reflexes
• Occulovestibular and occulocephalic reflexes
• A - Airway
• Gag relex
• L- Limbs
• Motor examination
• Reflexes
• Sensation

6. 6
Conscious level
• Glasgow coma scale
• Adelaide coma scale
• Blantyre coma scale for children
• Edinburgh coma scale
• Pittsburg brainstem score (PBSS)

7. 7
Glasgow coma scale
• Developed by Teasdale & Jennet
• Most widely used coma scale
• Eye opening -measure of arousal & alertness
• Motor response -measure of brain stem injury

8. 8
GLASGOW COMA SCALE=E+M+V
The score is determined by the sum of the score in each of the 3
categories, with a maximum score of 15 and a minimum score of 3
• For intubated patients –only E+M& suffix T given
• In intubated patients, the maximal GCS score is 10T and the minimum
score is 2T.
• Mild head injuries –GCS SCORE 13-15
• Moderate head injuries – GCS SCORE 9-12
• Severe head injuries-. GCS SCORE 8 or less

9. 9
Blantyre coma scale for children
• Modification of Glasgow coma scale
Response Findings Score
best motor
response
localizes painful stimulus (pressure with blunt end of pencil on sternum or
supraorbital ridge)
2
withdraws limb from painful stimulus (pressure with horizontal pencil on
nail bed of finger or toe)
1
no response or inappropriate response 0
best verbal
response
cries appropriately with painful stimulus, or, if verbal, speaks 2
moan or abnormal cry with painful stimulus 1
no vocal response to painful stimulus 0
eye movement watches or follows (e.g., mother's face) 1
fails to watch or follow 0

10. 10
Blantyre coma scale =
= (best motor response score) + (best verbal
response score) + (eye movement score)
Interpretation:
• minimum score: 0 (poor)
• maximum score: 5 (good)
• abnormal: score <= 4

11. 11
Edinburgh coma scale
• Developed in Japan
•Edinburgh-2 Coma Scale (1978)
•Set of Questions:
•(1) What month is it?
•(2) What is your age?
•Set of Commands:
•(1) Close and open your hand.
•(2) Close and open your eyes.

12. 12
Stimulation Best Response Score
2 set of question answers both correctly 0
answers either correctly 1
answers neither correctly 2
2 sets of commands obeys both correctly 3
obeys either correctly 4
obeys neither correctly 5
response to strong pain localizing 6
flexion 7
extension 8
no response 9
Interpretation of Edinburgh-2 Coma Scale:
• The lower the value the better the prognosis

13. 13
Pittsburg brainstem score (PBSS)
reflex Present (either side) absent
Lash reflex 2 1
Corneal reflex 2 1
Doll’s eye 2 1
Rt pupil reaction to light 2 1
Lt pupil reaction to light 2 1
Gag reflex 2 1
Pittsburg brainstem score=sum of all reflexes
Minimum score =6
Maximum score=12
Higher the score the better

14. 14
Rationale of Coma scales
• Rationale for developing & using coma scales
is :
1. Need for sequential follow up to assess potential worsening
2. Need for a standardized baseline measure for comparison with
later measures to determine prognosis
3. Development of coma scale is facilitated by simple neurological
examination which can be performed on stuporous patient
4. Critical neurological parameters include state of conciousness,
pupil & eye movement, best motor response,& nature of
respiratory effort
5. Quantification of some or all of these parameters into an easily
codable system is a coma scale

16. HEAD INJURIES
• These may include injuries of the scalp, skull, brain, and
blood vessels.
• Scalp Injuries
• 1. Laceration of the scalp may be associated with significant
bleeding. Control with deep sutures and compression dressing. Prophylactic
antibiotics for Scalp infections as they may spread intracranially
via the emissary veins.
• 2. Skull fractures are described according to shape,
displacement, site and integrity of the overlying skin. Thus we
have, for example, linear, stellate, comminuted, depressed,
compound, and basilar fractures.
• A fracture can be diagnosed by digital exploration of the wound,
radiographically or clinically. The diagnosis of basilar fractures is often
clinical:
• CSF leaking from the nose or ear.
• Periorbital ecchymosis (raccoon eyes).
• Ecchymosis behind the ear (Battle's sign).

17. Management of Scalp injuries
• Scalp lacertations:Copius irrigation to cleanse the wound, carefull
debridement. Closure in layers
• Scalp avulsions: copius irrigation, trimming of edges. Primary closure
if avulsion is small. Large area to be covered with suitable flap or left
with external dressing for secondary healing.

19. Skull fractures
• Skull fractures are described according to shape, displacement,
site and integrity of the overlying skin. Thus we have, for
example, linear, stellate, comminuted, depressed, compound,
and basilar fractures.
• A fracture can be diagnosed by digital exploration of the wound,
radiographically or clinically. The diagnosis of basilar fractures is often
clinical:
• CSF leaking from the nose or ear.
• Periorbital ecchymosis (raccoon eyes).
• Ecchymosis behind the ear (Battle's sign).
• Skull fracture predispose a conscious to about 400 times the
possibility of cranial haematoma and about 20 times in a comatose
patient
• Classified as:
• Closed/open
• Linear/stellate/communited
• Depressed / non depressed

20. • Types of skull fracture:
• Linear- from the point of impact along lines of anatomical weakness (eg
diastasis of suture fusion lines).
frontal fracture (eg head-on RTA) often radiates into anterior cranial fossa
temporal fracture (eg blow to side of head) often radiates into middle cranial
fossa
occipital fracture (eg backwards fall) often radiates into posterior cranial fossa
• Radiating- outwards from the point of impact
• Spider's web- radiating lines connected by concentric fracture rings
• Depressed- where fragments are driven inwards
• Hinge- passing across the base of the skull (motor cyclist or blow to chin)
• Ring- encircling the hole through which the spinal cord passes downwards
(foramen magnum). Due to a fall onto the feet or onto the top of the head
• Contre-coup- a backwards fall, striking the back of the head (coup) may also
cause fracture of the thin layer of bone over the roof of the orbits opposite
the point of impact (contre-coup) due to suction forces transmitted through
the brain tissue.

21. Management
• Closed non depressed fractures:- observation and monitoring
and medical line of treatment for associated intracranial
parenchymal injury
• Open non depressed fractures:- close observation, surgical
intervation if intracranial bleed is suspected/anticipated
• Depressed skull fractures:- observation, if no untoward
neurological sign exists than the operation may be delayed and
elevation of the fractured segment is done

22. Basal skull fractures
• Associated tear of the dura and arachnoid at the base of the
skull/ middle or anterior cranial fossa
• Battles sign is suggestive of basal skull fracture
• A CSF fistula occurs in 70 % patients with in 48 hours of
trauma
• 98% of fistulae occur with in 3 months
• Post traumatic fistulae heal spontaneously with in week, and
80% heal with in 6 months.
• Spontaneous reoccurance may be there after initial cessation
• Otoroheas almost always resolves spontaneously and delayed
otorrhea is rare
• Chronic fistulae are indicated for surgical repair

23. BASE OF SKULL
FRACTURE

24. C/F
• Headache
• Decreased hearing
• Salty taste in mouth
• Pneumocephalus present in 30% of the patients
Diagnosis
Bed side: ring test
tram line
Lab test: glucose >30mg/dl
protein < 2/l
presence of b2 transferrin

25. Management
• There may be presence of meningitis - Prophylactic
antimicrobials (3rd generation cephalosporins)
• Head elevated to 30 degrees, cautioned againts blowing nose,
forcefull coughing
• If leak persists for more than 72 hours, lumbar puncture is
indicated to reduce ICP
• Fewer than 5% patients require repair. Immediate surgical
intervention is indicated only open communited fractures with
CSF leak
• Delayed surgical repair is indiacted in
• Persistent or increased CSF leakage over 1 or 2 weeks
• Presence of unresolving pneumocephalus for more than a week
• meningitis

26. Physical Examination
• 1. Assess level of consciousness. Use the Glasgow Coma Scale. The minimum
score is 3 and the maximum score is 15. An intubated patient has a maximum
GCS 11T. A score of 8 or less signifies severe brain damage and the
prognosis is guarded.
• 2. Check pupils (size, reaction to light).
• 3. Check ears and nose for bleeding or CSF leakage.
• 4. Check for ecchymosis around the eyes or behind the ears (basilar
fracture).
• 5. Check cranial nerves.
• 6. Exclude neck injury (neck pain, stiffness, tenderness, or paralysis are
suspicious signs).
• 7. Limbs (strength, tone, reflexes)
• 8. Vital signs (blood pressure, pulse, respiration, temperature)
• 9. Associated injuries

27. Brain Injuries
• As defined by the National Head Injury Foundation
• “a traumatic insult to the brain capable of producing physical,
intellectual, emotional, social and vocational changes.”
• 1. Concussion: No gross pathology. Transient loss of
consciousness. CT scan is normal.
• 2. Contusion: Bruising of the brain surface underneath a
fracture or at the under-surface of the frontal and temporal
lobes, due to shearing forces. Diagnosed on CT scan.
• 3. Laceration: Tearing of the brain substance. Diagnosed by CT
scan.
• 4. Brain edema: This is localized in the glial cells, myelin
sheaths, and intercellular spaces. It causes increased intracranial
pressure, which may impair brain circulation, or result in brain
herniation. It may be missed in early CT scans. Later CT scans or
MRI show edema more reliably.

28. • Altered Mental Status
• Altered orientation
• Alteration in personality
• Amnesia
• Retrograde
• Antegrade
• Cushing’s Reflex
• Increased BP
• Bradycardia
• Erratic respirations
Signs & Symptoms of Brain Injury
Vomiting
 Without nausea
 Projectile
Body temperature changes
Changes in pupil reactivity
Decorticate posturing

29. • Pathophysiology of Changes
• Frontal Lobe Injury
• Alterations in personality
• Occipital Lobe Injury
• Visual disturbances
• Cortical Disruption
• Reduce mental status or Amnesia
• Retrograde
• Unable to recall events before injury
• Antegrade
• Unable to recall events after trauma
• “Repetitive Questioning”
• Focal Deficits
• Hemiplegia, Weakness or Seizures
Signs & Symptoms of Brain Injury

30. 30
Cerebral concussion
• A concussion is defined as physiologic injury to the
brain without any evidence of structural alteration
• Concussions are graded on a scale of I-V
• Grade I : A grade I concussion is one in which a person is confused
temporarily but does not display any memory changes.
• Grade II: In a grade II concussion, brief disorientation and anterograde
amnesia of less than 5 minutes' duration are present
• Grade III: In a grade III concussion, retrograde amnesia & loss of
consciousness for less than 5 minutes are present, in addition to the 2
criteria for a grade II concussion.
• Grade IV: Grade IV concussion is similar to grade III concussion
except that in a grade IV concussion, the duration of loss of consciousness
is 5-10 minutes.
• Grade V: In Grade V concussion, retrograde amnesia & the loss of
consciousness is longer than 10 minutes.
•

31. • Brain damage is classified into:
• 1. Primary brain damage. It occurs at the time of injury
and is irreversible (i.e. lacerations, contusions, axonal
injuries of the white matter due to shearing forces).
• 2. Secondary brain damage. It occurs at a later stage due
to tissue hypoperfusion and may be preventable and
reversible. Conditions that may cause secondary brain
damage:
• Extracranial causes: shock, hypoxia, and electrolyte
abnormalities.
• Intracranial causes: hematoma, brain edema, infection, and
hydrocephalus
• A minimum CPP of 70 mm Hg (or >50 mmHg in young
children)
(CPP = mean arterial pressure (MAP) – intracranial)

32. Intracranial Bleeding
• 1. Epidural hematoma: Usually due to laceration of the middle
meningial artery or venous sinuses. Commonly located in the
temporal or parietal region, often with associated fractures. On
CT scan it appears as a hyperdense, biconvex-shape lesion.
• 2. Subdural hematoma:
• a. Acute subdural: It manifests within the first few hours of injury. It is due to
bleeding from injured brain tissue or from the veins, which bridge the cortex with
the cavernous sinus. On CT scan it appears as a crescentshape, hyperdense
lesion.
• b. Chronic subdural: It may appear many days, weeks or months after the injury.
More common in elderly patients. On CT scan it shows as a crescent-shape,
hypodense lesion.

33. • 3. Intracerebral hematoma: Usually beneath a cortical contusion.
• 4. Subarachnoid hemorrhage: It often gives symptoms and signs of Meningial
irritation: headache, photophobia, neck stiffness, fever. The mental status may
vary from confusion to coma. On CT scan it appears as linear, highdensity areas
following the sulci, often in the Sylvian fissure. The blood is usually absorbed
by the CSF. It may cause late hydrocephalus because of obstruction of the CSF
circulation.
• A catastrophic complication in patients with intracranial hematomas is
herniation of the temporal lobe through the tentorium and compression of the
brain stem. Symptoms and signs:
• 1. Dilatation of the ipsilateral pupil, due to compression of the third nerve. In the
early stages there may be transient constriction due to stimulation of the nerve.
• 2. Depressed level of consciousness, due to compression of the reticular formation
• 3. Contralateral hemiparesis, due to compression of the cerebral peduncle
• 4. Bradycardia
• 5. Elevated blood pressure
• 6. Irregular respiration

34. Ocular function
• Reaction of pupils to light
• Extraocular muscle function
• Oculovestibular and oculocephalic reflexes
• Corneal reflex
• Gag reflex

35. Cranial nerve examination
• Olfactory nerve
• Optic nerve
• Occlumotar
• Trochlear
• Abducent
• Trigeminal nerve
• Facial nerve
• Vestibular nerve
• Glossopharyngeal nerve
• Spinal accesory nerve
• Hypoglossal nerve

36. Upper motor lesion Vs lower Motor
lesion
• Mucle groups
• Rigid
• Slight wastine
• Flexor spams
• Brisks jerks
• Plantars extensor
• Normal electrical
reaction
• Individiual
• Flaccid
• Marked wasting
• Fasciculation
• Deep jerks absent
• Flexor plantars
• No or little reaction

37. Motor nerve examination• Grade 0 – no motor activity
• Grade 1 – papable muscle contraction
• Grade 2 – complete range of motion with gravity eliminated
• Grade 3 – complete range of motion against gravity
• Grade 4 - complete range of motion against gravity with
resistance
• Grade 5 – complete range of motion against gravity with
complete resistance
Gait
• Casual , heal to toe and tandem walking to be examined
• Cerebellar dysfunction can cause ataxia of gait
• Unilateral cerebellar lesion will produce staggering toward the affected side (
typicall walk with the legs apart)
Coordination
• Ability to perform finger to nose, heel to shin, and rapid alternative
movements
• Hemispheric cerebellar disease usually lateralize, middle vermian lesions
affect bilaterally

38. Sensory system
• Grade 0 – absent
• Grade 1 – present
• Grade 2 – normal
• Grade 3 – normal active
• Grade 4 – hyperactive
• Grade 5 – hyperactive with Clonus
Jaw jerk
Bicep jerk
Suppinator jerk
Tricep jerk
Knee jerk
Angle jerk
Babinskis sign

40. Diagnostic tests
• 1. Plain skull x-rays only if CT scan is not available (may show fractures, foreign
bodies, air in the skull, shifting of calcified midline structures). A linear
fracture increases the risk of intracranial hematoma by 400 times.
• 2. Cervical spine x-rays and CT scan for all unconscious patients and those with
suspicious symptoms (local tenderness, neurological signs).
• 3. CT scan: This is the most important diagnostic tool.
• Indications: All patients with history of loss of consciousness, amnesia,
depressed level of consciousness, headache and localizing signs should have
a CT scan investigation. Subsequent CT scan may be necessary if there is
deterioration of the neurological status.
• 4. Carotid angiogram (limited use). It might be useful in some penetrating
injuries, especially with retained knife blades or bullet injuries.
• 5. Intracranial Pressure (ICP) monitoring: It is an essential diagnostic,
monitoring, and therapeutic modality in severe head injuries. The CPP
(Cerebral Perfusion Pressure) is much more important than ICP absolute
values. Maintain a CPP >70 mmHg or >50 mmHg in young children.
SEND FOR NEUROLOGICAL CONSULTATION

41. Epidural Hematomas
• Blood between
inner table of the
skull and the dura
• Lens shaped
hematomas that do
not cross suture
lines on CT

42. Subdural Hematomas
• Blood beneath the
dura, overlying the
brain and arachnoid,
resulting from tears to
bridging vessels
• Crescent shaped
density that may run
length of skull
• Very common in the
elderly

43. Subarachnoid Hemorrhage
• Bleeding beneath the
arachnoid membrane
on the surface of the
brain.

44. Intracranial Hematoma
• Focal areas of
hemorrhage
within the
parenchyma

45. 45
Marshall’s classification
• Classifies head injuries according to the changes
demonstrated on CT scan images.
• Diffuse injury 1: Evidence of any significant brain injury is lacking.
• Diffuse injury 2: Either no midline shift or a shift of less than 5 mm is
present .
• Diffuse injury 3: A midline shift of less than 5 mm is present,
withpartial compression or absence of the basal cisterns.
•
• Diffuse injury 4: Defined as midline shift greater than 5 mm with
compression or absence of the basal cisterns.

46. Managemet of Mild Head injury
GCS 14 - 15
• History
• Name/Age/Sex
• Mechanism of Injur
• +/- loss of consciousnes
• Level of alertness
• Amnesia –
Retrograd/anterograde
• Head ache- mild/moderate/sever
• +/-seizure
• GPE
• Limited
neurological
examination
• Cervical spine
radiographs
• Blood alcohol
• CT scan
• Admit/observe
• No CT Scan/Abnormal CT scan
• Penetrating Head Injuries
• Deteroriting Condition
• Moderate/sever head ache
• Alcohol intoxification
• Skull fracture
• CSF leak
• Amnesia
• H/O unconsciousnes
• Discharge
• Schedule follow up
with in 1 week

47. Management of Moderate head Injury
(Flow Chart)
GCS 9-13
Admission
CT Scan of Brain
If patient improves discharge if patient detoriates,
manage
as per severe head injury

48. Management in Case of Sever head
injury GCS score 3-8
• ABC
• Previous history for allergies,
medications, past illness, last
meals and events leading to
head injury
Neurologic Reevaluation
• Eye opening
• Motor response
• Verbal response
• Pupillary light reaction
• Occulo cephalics reflex
• Occulo vestibular reflex
Therapeutic Agents
• Mannitol
• Moderate
hyperventilation
• Anticonvulsants if
requireed
• CT scans
• Air
Venticulogr
am
• Angiogram

49. Cervical Spine Injuries
• Only 2% incidence of cervical spine injuries in maxillofacial
trauma patients
• Identification of obvious fracture , widening of posterior spina
process interspace
• CT scan is choice of diagnostic radiographic tool
• Emergency management include:
• ABC
• C-Spine stabilization using rigid and semi rigid collars
• 30mg/kg predisonolone bolus followed by 5.4g/kg/hr for 24 hours
• Definitive management include skeletal traction, with the use of halo
traction with stryker frame with abouts 25 pounds of traction force

50. Orbital injuries
• Opthalmic exatmination:
• Visual accuity
• Enoptholmoses/proptosis/diplopia
• Eye movement
• Size , level and reaction of pupils
• Intra occular examination of choroid, anterior chamber, cornea,iris
• Extra ocular examination
• Lid integrity
• Nasolacrimal duct injury
• Echymosis
• Ptosis

52. Hutchinson’s pupil
52
•Seen in case of cerebral compression
•Consists of 3 stages
Pupil of the side of injury
contract
due to irritation of
occulomotor nerve
Pupil on other side -normal
pupil of the injured side
becomes
dilated due to paralysis of
occulomotor
nerve
Pupil of other side contracts
Pupils of both sides dilated, no
reaction
to light

53. Pupillary response inference
Bilaterally reactive pupils that react to
both direct & consensual stimuli
Normal pupil
Bilateral small pupils Narcotics, pontine injury, early central
herniation on the pons
Bilateral fixed & dilated pupils Inadequate cerebral perfusion,severe elevation
of ICP preventing adequate blood flow to brain
Unilateral fixed & dilated pupils. pupil that
does not constrict when light is directed at the
pupil but constricts when light is directed to
contralateral pupil
Traumatic optic nerve injury
(Marcus Gun pupil)
A core optic pupil (pupil that appears irregular
in shape)
Lack of coordination of contraction of the
muscle fibers of the iris and is associated with
midbrain injuries
Unilateral dilated pupil that does not respond
to either direct or consensual stimulation
Transtentorial Herniation
53

54. 54
Cranial nerve 3,4,6:
- light reflex
- intorsion and extorsion

55. Vision-threatening injuries
(VTI)• These include:
• Retrobulbar haemorrhage;
• Traumatic optic neuropathy;
• Open and Closed globe injuries;
• Loss of eyelid integrity;
• Chemical injury.
• Loss of sight following blunt facial trauma may be crudely considered to be
due to the following mechanisms.
• Direct injury to the globe;
• Direct injury to the optic nerve, e.g. bony impingement;
• Indirect injury to the optic nerve, e.g. deceleration injury resulting in shearing,
stretching forces;
• As a result of a generalised or regional fall in tissue perfusion (anterior ischaemic
optic neuropathy,
• retrobulbar haemorrhage, nutrient vessel disruption);
• Loss of eyelid integrity

56. Retrobulbar haemorrhage
• A tense, proptosed globe and a dilated pupil may be the only clues to
the presence of a retrobulbar haemorrhage
• A lateral canthotomy, with lateral canthal tendon division, can be
performed under local anaesthesia in the emergency setting.
Lignocaine 1%, with adrenaline (1 in 200,000), is injected into the
lateral canthal area of the affected eye, the lateral canthus incised to
the orbital rim and the canthal tendon identified and cut. The lower
eyelid is then pulled forward and its lateral attachment to the orbital
rim divided.
• This allows the globe to translate forward, partially relieving the
pressure by increasing the retrobulbar volume. If necessary, the
same procedure can also be applied to the upper eyelid laterally.
Formal decompression is then carried out under a general
anaesthesia

58. CHEST INJURIES
Rib trauma is occurs in aout 56% of poly trauma patients followed by
pneumothorax, flail chest, injuty to heart and major vessles
• Degree of injury to chest is not indicative of the severity of injury to inner
structures
• During the Primary Survey, the following life-threatening conditions from the
chest should be identified and treated:
• 1) Tension pneumothorax
• 2) Fail chest
• 3) Open, blowing chest wound
• 4) Massive hemothorax
• 5) Cardiac tamponade
• During the Secondary Survey, the following injuries should be identified and
treated:
• 1) Contained rupture of the aorta
• 2) Perforation of the tracheobronchial tree
• 3) Perforation of the esophagus
• 4) Rupture of the diaphragm/trachea
• 5) Myocardial contusion
• 6) Pulmonary contusion

59. • PNEUMOTHORAX
Definition: The presence of free air in the pleural cavity.
• Symptoms and signs
• 1. Often asymptomatic.
• 2. Dyspnea, tachypnea.
• 3. Diminished breath sounds, hyperresonance, poorly
moving hemithorax.
• Investigations
• Chest x-ray, preferably erect and in expiration

60. • HEMOTHORAX
Definition: Free blood in the pleural cavity.
• Symptoms and signs
• 1. Often asymptomatic.
• 2. Dyspnea, tachypnea, hypovolemia.
• 3. Diminished breath sounds, dullness on
percussion, poorly moving hemithorax

61. • TENSION PNEUMOTHORAX
Definition: Air under pressure in the pleural cavity due
to a valve effect. Associated with life-threatening
cardiorespiratory compromise due to collapse of the
affected lung, compression of the normal lung and
decreased venous return.
• Symptoms and signs
• Dramatic presentation. Panicky patient.
• Dyspnea, cyanosis, tachypnea,
• Shock, distended neck veins.
• Deviated Trachea to opposite side
• Absent breath sounds, hyperresonance on affected side.
• Prominent hemithorax with no movement on respiration

62. Flail Chest
• Occur as a result of three or more contigous ribs fracturedd at
two points
• Lateral type of flail chest is more common
• Anteior type occures when ribs become separated at the
costrochondral junction, with or without associated fracture of
sternum.
• The posterior type occurs whe n the posterior ribs are
fractured
• Pulmonary contusion, hemothorax and pneumothorax may be
associated with flail chest,
• Mechanical ventilation is indicated
• Tachyapnea
• Shallow rapid breaths
• Distended neck veins
• hypercapnea

63. Placement of thoracic tube

64. Abdominal Injuries
• The abdomen is systemically examined by inspection,
palpation and auscullation and percussion
• Injury to be suspected in deacceleration injuries, blunt
trauma apart from penatrative injuries
• Presence of haematuria in Routine urine examinatio
may indicate a renal/genito urinary trauma
• Serum amylase a non specific test in presence of
abdominal pain is significant
• LFT should also be advised to check liver injuries
• Dignostics include USG, CT Scan PA abdomen and DPL

65. DPL (diagnostic peritonial
Lavage)• Indicated in patients with + H/O abdominal trauma with
abdominal pain /tenderness.
• Objective is to obtain fluid from the pelvic fossa for analysis
• Bladder should be emptied to avoid injury during DPL.
• Aspiration of fluid is done, if no fluid is obtained tha n 20ml/kg of
RL is infused upto 1 Litre and removed fluid should atleast be in
range of 500-700 ml.
• Three methods:
• Closed type: catheter blindly inserter below the umblicus in to the
peritoneal cavity. Highest incidence of complication, false negative tests
and iatrogenic injury to visecral organs
• Semiopen type: 2-3 cm infraumblical skin incision, blunt dissection.
Incision into fascia. Insertion of trocar
• Open technique: insertion of the catheter direct vision. Safest and
guarantees intraperitoneal placement

67. Managemet of abdominal
injuries
• Physical examination to be repeated every 6 hourly
• Management of shock, sepsis
• Surgical exploration and intervention when necessary
• Monitoring of urine output every hourly
• Patient to be NPO
• Nutritional support

68. Urological injuries
• Occurs in 10% polytrauma patients
• Majority of injuries are non threatning
• Evaluation of kidneys, ureter, bladder, urethra and genitila
• Excellent healing capibilities of genitourinary tract, if urinary
flow can be maintained without obstruction than healing is
likely with just medical intervention
• Kidney is the most common urologic organ to be injured
• CT scan is the gold standard for diagnosing renal injuries

71. Skeletal injuries

72. Retrograde intubation

73. Submental intubation