Head injury: A serious surgical problem.


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Head injuries top the list of trauma patienrts coming to the casualty. The condition has to be immediately assessed and investigated. Depending upon the findings prompt medical or neurosurgical treatment has to be administered.

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Head injury: A serious surgical problem.

  1. 1. Head Injuries Dr. Ketan Vagholkar M.S.(BOM)., D.N.B., M.R.C.S.(GLASGOW)., F.A.C.S. Consultant General Surgeon & Professor of Surgery
  2. 2. Head Injuries <ul><li>Learning Objectives </li></ul><ul><li>Understanding the basic sciences related to pathophysiology of head injuries </li></ul><ul><li>Clinical evaluation </li></ul><ul><li>Management </li></ul><ul><li>Medicolegal documentation </li></ul>
  3. 3. Pathophysiology <ul><li>Monro Kellie Hypothesis. </li></ul><ul><li>Cerebral Edema </li></ul><ul><li>vasogenic-bbb affected </li></ul><ul><li>cytotoxic-bbb unaffected </li></ul><ul><li>osmotic-bbb intact </li></ul><ul><li>interstitial- csf brain barrier affected </li></ul><ul><li>Conning </li></ul><ul><li>subfalceal </li></ul><ul><li>trans tentorial- Kernohans notch </li></ul><ul><li>trans foramen magnum </li></ul>
  4. 4. Primary management of trauma patient <ul><li>Airway </li></ul><ul><li>Breathing </li></ul><ul><li>Circulation </li></ul><ul><li>Clinical assessment </li></ul>
  5. 5. Clinical Features <ul><li>History </li></ul><ul><li>Mechanism of injury/impact, </li></ul><ul><li>Unconsciousness, </li></ul><ul><li>Vomiting, </li></ul><ul><li>Convulsions, </li></ul><ul><li>ENT bleed, </li></ul><ul><li>Alcoholism, </li></ul><ul><li>Diabetes, </li></ul><ul><li>Hypertension, </li></ul><ul><li>TIA’s </li></ul><ul><li>PhysicalExamination </li></ul><ul><li>Pulse </li></ul><ul><li>Blood pressure </li></ul><ul><li>Respiratory rate </li></ul><ul><li>Glasgow coma scale </li></ul><ul><li>Local examination of the head for scalp injuries & depressed fractures </li></ul>
  6. 6. Glasgow Coma Scale
  7. 7. <ul><li>Detailed documentation of vital and neurological parameters </li></ul>
  8. 8. Neurological Examination <ul><li>Position of patient </li></ul><ul><li>Depth of unconsciousness </li></ul><ul><li>Eyes ; Black eye (Periorbital ecchymosis) </li></ul><ul><li>: Pupils – size, equality and reaction to light </li></ul><ul><li>Examination of ears and nose for blood or csf leak </li></ul><ul><li>Power in the limbs and reflexes </li></ul><ul><li>Cranial nerves </li></ul><ul><li>Examination of neck </li></ul>
  9. 9. Coup and Contre- coup injuries <ul><li>Scalp laceration </li></ul><ul><li>Skull fracture </li></ul><ul><li>Extradural hematoma </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Cerebral laceration and contusion </li></ul><ul><li>Brain edema </li></ul><ul><li>Intracerebral hematoma </li></ul><ul><li>- </li></ul><ul><li>- </li></ul><ul><li>- </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Cerebral laceration and contusion </li></ul><ul><li>Brain edema </li></ul><ul><li>Intracerebral hematoma </li></ul>
  10. 10. Examination of Neck <ul><li>Every head injury patient is assumed to have sustained a neck injury unless proved otherwise hence detatiled evaluation of neck for injuries is pivitol </li></ul><ul><li>Cervical (neck) injuries usually result in full or partial tetraplegia ( Quadriplegia ). However, depending on the specific location and severity of trauma, limited function may be retained. </li></ul><ul><li>Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing . </li></ul><ul><li>C3 vertebrae and above : Typically results in loss of diaphragm function, necessitating the use of a ventilator for breathing. </li></ul><ul><li>C4 : Results in significant loss of function at the biceps and shoulders. </li></ul><ul><li>C5 : Results in potential loss of function at the shoulders and biceps, and complete loss of function at the wrists and hands. </li></ul><ul><li>C6 : Results in limited wrist control, and complete loss of hand function. </li></ul><ul><li>C7 and T1 : Results in lack of dexterity in the hands and fingers, but allows for limited use of arms. </li></ul><ul><li>Patients with complete injuries above C7 typically cannot handle activities of daily living and cannot function independently.[ citation needed ] </li></ul><ul><li>Additional signs and symptoms of cervical injuries include: </li></ul><ul><li>Inability or reduced ability to regulate heart rate , blood pressure , sweating and hence body temperature . </li></ul><ul><li>Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances. </li></ul>
  11. 11. Other Examinations <ul><li>Thorax </li></ul><ul><li>External injuries </li></ul><ul><li>Movements of the chest </li></ul><ul><li>Auscultation of the chest </li></ul><ul><li>Abdomen </li></ul><ul><li>External injuries </li></ul><ul><li>Tenderness, rebound tenderness </li></ul><ul><li>Guarding , rigidity </li></ul><ul><li>4 quadrant tap if required </li></ul><ul><li>Skeletal examinations </li></ul><ul><li>Limb fractures </li></ul>
  12. 12. Admission to hospital for all head injury patients is a safe practice <ul><li>Always give a equivocal or a accurate picture regarding the severity of injury and a uncertainty regarding the variable outcome to avoid illusion in the minds of the relatives </li></ul><ul><li>Close observation of neurological status </li></ul><ul><li>Early detection of neurological deterioration and avoiding delay in neurosurgical intervention </li></ul><ul><li>Allays the anxiety of relatives </li></ul><ul><li>Quick transfer to a neurosurgical facility if in a peripheral hospital </li></ul><ul><li>Medico legally safe and defensive for the attending clinician </li></ul>
  13. 13. Investigations <ul><li>Hematological </li></ul><ul><li>CBC </li></ul><ul><li>Blood sugar levels </li></ul><ul><li>BUN </li></ul><ul><li>Creatinine </li></ul><ul><li>Electrolytes </li></ul><ul><li>Blood grouping in severe cases </li></ul><ul><li>Toxicology scan in suspected drug ingestions </li></ul><ul><li>Radiolgy </li></ul><ul><li>Plain CT scan of brain </li></ul><ul><li>Cervical spine x-ray preferably in all head injury patients </li></ul><ul><li>3D CT scan of the skull in suspected facial bone fractures </li></ul><ul><li>Plain x-rays depending upon the injuries e.g. open mouth view, nasal spine, paranasal sinuses, </li></ul>
  14. 14. Treatment Objectives <ul><li>Treatment of raised intracranial tension due to cerebral edema </li></ul><ul><li>Treatment /prevention of convulsions </li></ul><ul><li>Treatment of scalp injuries </li></ul><ul><li>Treatment of skull fractures </li></ul><ul><li>Treatment of intracranial hematomas </li></ul>
  15. 15. Treatment of raised intracranial tension due to cerebral edema <ul><li>Elevation of the patient’s head to promote venous drainage </li></ul><ul><li>Hyperventilation if GCS greater than 5 </li></ul><ul><li>Increasing the serum osmolality to approx 300-310 mOsm/lit by administering mannitol ( in adults bolus dose of 1 gm followed by maintainance dose of 0.25-0.50 gms evey 6 hourly) however the effect remains for not more than 48 hours </li></ul><ul><li>Loop diuretics such as lasix in patients with comorbid problems </li></ul><ul><li>Barbiturates as the last resort, best given in a neurosurgical facility </li></ul>
  16. 16. Treatment /prevention of convulsions <ul><li>Eptoin sodium is the drug of choice </li></ul><ul><li>In patients who have had a convulsion </li></ul><ul><li>Loading dose of 300mgms followed by maintenance dose of 100mgms every 8 hourly converted to oral dosage at discharge and continued for 2 years </li></ul><ul><li>In patients who have not convulsed but have intracranial pathology </li></ul><ul><li>Prophylactic dosage of 100mgm every 8 hourly converted to oral dosage at the time of discharge and continued for a period of 6 months </li></ul>
  17. 17. Treatment of scalp injuries <ul><li>Shave the surrounding hair to have minimum clearance of 1 inch all around the wound </li></ul><ul><li>Rigourous cleansing of the wound ensuring complete removal of all foreign materials </li></ul><ul><li>Adequate hemostasis of bleeding scalp vessels by eversion of scalp layers or by pressure tamponade </li></ul><ul><li>Exact assessment of the depth of the wound with regards the layers of the scalp and if breached whether aponeurosis breached or intact </li></ul><ul><li>Limited debridement only in badly contused and irregularly lacerated wounds. </li></ul><ul><li>Chromic catgut 1-0 for aponeurosis suturing </li></ul><ul><li>Prolene or ethilon 1-0 for skin and superficial layers of scalp </li></ul><ul><li>Antibiotics, analgesics and tetanus prophylaxis </li></ul>
  18. 18. Treatment of skull fractures <ul><li>Linear fracture- conservative treatment </li></ul><ul><li>Depressed fracture- requires surgery if significantly depressed </li></ul><ul><li>Diastatic fractures which involve sutures usually lambdoid - conservative treatment </li></ul><ul><li>Basilar fractures- conservative tratment- if CSF leak persist than osteoplastic flap surgery at a latter date </li></ul><ul><li>Compound skull fractures- conservative treatment to start with followed by surgical intervention at a latter date if required. </li></ul>
  19. 19. Treatment of intracranial hematomas <ul><li>Extradural Hematoma </li></ul><ul><li>Location Between the skull and the dura </li></ul><ul><li>Involved vessel </li></ul><ul><li>Temperoparietal locus (most likely) - Middle meningeal artery Frontal locus - anterior ethmoidal artery Occipital locus - transverse or sigmoid sinuses Vertex locus - superior sagittal sinus </li></ul><ul><li>Symptoms Lucid interval followed by unconsciousness CT </li></ul><ul><li>Appearance Biconvex lens </li></ul><ul><li>Treatment Exploratory craniotomy with evacuation of the hematoma </li></ul>
  20. 20. Treatment of intracranial hematoma <ul><li>Subdural Hematoma </li></ul><ul><li>Lcation ;Between the dura and the arachnoid </li></ul><ul><li>Involved vessel Bridging veins </li></ul><ul><li>Symptoms Gradually increasing headache and confusion </li></ul><ul><li>( acute,subacute and chronic presentation) </li></ul><ul><li>Appearance Crescent -shaped </li></ul><ul><li>Treatment craniotomy with evacuation of hematoma </li></ul>
  21. 21. Treatment of intracranial hematoma <ul><li>Intracerebral hematomas have very poor prognosis </li></ul><ul><li>Surgical debridement may be attempted in a few cases but with poor results </li></ul><ul><li>Post traumatic Subarachnoid hemorrhage is treated conservatively and has doubtful prognosis. </li></ul>
  22. 22. Late Complications of head injuries <ul><li>Post traumatic headache </li></ul><ul><li>Post-traumatic epilepsy </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Memory Changes </li></ul>
  23. 23. Medicolegal documentation <ul><li>Note should be made about the informant </li></ul><ul><li>Detail list of injuries along with diagrams is strongly advised </li></ul><ul><li>Dimensions in cms should be mentioned </li></ul><ul><li>Injury certificate should contain clinical examination injury findings as well as lesions picked on Ct or any other radiological examination. </li></ul><ul><li>While in hospital the level of consciousness (GCS) and vital parameters should be documented on a periodic basis till the patient achieves neurological and hemodynamic stability </li></ul><ul><li>All short term and long term sequelae of the lesion should be explained to the patient and his close relatives at the time of transfer or discharge. </li></ul>
  24. 24. Pupillary Changes in head injury patients
  25. 25. Clinical signs in head injury patients
  26. 26. Extradural Hematoma
  27. 27. Subdural Hematoma
  28. 28. Intracerebral Hematoma
  29. 29. Skull fractures
  30. 30. Thank You