HEAD INJURY AND TRUMATIC BRAIN INJURYDr.Mansoor KhanMBBS, FCPS-I,Resident SCW, KTH, Peshawar Mar14th, 2009
“Traumatic Brain Injury is aninsult to the brain caused by an external physical force”
TBI CLOSED HEAD OPEN HEAD INJURY INJURYNo obvious external signs, Obvious external woundresulting from –motor vehicle For example a gunshot woundcrashes, falls, child abuse, or or object penetrating the skull.domestic violence, childviolence..
Highest among adolescents, young adults, and those older than 75 50% of major trauma deaths are due to TBI Vehicle crashes are the leadingcause of brain injury. Falls are the second leading cause
CONCUSSION When the brain suddenly shifts inside the skull and knocks against the skulls bony surface. Concussions can last from a few moments, to an unconscious state for over 3 minutes.
CONCUSSION Grade 1 – conscious, symptoms last under 15 minutes Grade 2 – conscious, symptoms last over 15 minutes Grade 3 - unconsciousGrade 1 Grade 2 Grade 3Allow casualty to Seek professional Call an ambulancerest, however medical assistance, immediately, lay casualty down with head andcontinually monitor in lay the casualty down shoulders slightly raised,case their condition with the head and try to keep them awakechanges. Lay shoulders slightly and talking. If casualtycasualty down with raised. Try to keep falls unconscious and istheir head and casualty awake and not breathing,shoulders slightly talking commence CPR and monitor vital signsraised
Bra in ull Sk Are a bru of isin g Site imp of act Con bru tusion i , ma sing o or y f of t occu the br he r blo at the ain w. sitePOSSIBLE SITE OF BRAIN INJURY FOLLOWING A BLOW TO BACK OF HEAD BRAIN CONTUSIONS
BRAIN CONTUSION Conduct Primary Survey If symptoms indicate severe head trauma, call ambulance Monitor casualty’s level of consciousness If casualty falls unconscious and breathing ceases, commence CPR until further help arrives
EXTR-DURAL HEMATOMA Blow to the temporal, parietal bone Rupture of the middle meningial artey Initial concussion followed by lucid interval Respects the suture lines. Seen on CT Brain as lens- shaped blood collection with a convex medial border . Carries a 5% to 20% mortality rate
SUB-DURAL HEMATOMA Severe head injury-Sudden deceleration injuries Rupture of a bridging vein Thin layer of blood in the subdural space Crescent-shaped blood collections with a concave medial border. This does not resect the suture lines. Note also midline shift.
SUB-ARACHNOID HEMORRHAGE Increased attenuation is seen in the CSF spaces over the cerebral hemispheres Bleeding occurs between the arachnoid and pia mater
INTRA-CEREBRAL HEMORRHAGE Injury of the brain substance itself Associated with cerebral laceration, contusion, oedema and necrosis Evacuation of the clots can have poor results Not as easy to remedy.
DIFFUSE AXONAL INJURYOccurs due to shearing forces between grey and white matter. Generalized cerebral oedema resultsdue to parenchymal disruption leadsing to an increase in ICP Ranges from mild form-concussion severe form- persistent vegetative state
Mild Head injury. GCS 13 – 15 80%Moderate Head injury GCS 9 – 12 10%Severe Head injury GCS < 9 10%
GCS<13 at any point When to do CT- Scan -GCS 13-14 at 20 LoC or ante grade amnesiaFocal deficit +? Open/depressed/Basal # Age ≥ 65Post-traumatic seizure Coagulopathy/warfarin> 1 vomiting episode - + - + Get help! Dangerous Mex: pedestrian rta, ejection, fall > 1m / 5stairs. CT within 1hr Retrograde amnesia>30mins + - CT within 8hrs No imaging now
P Deep cuts or tears to the scalpR NauseaE VomitingS Severe headache Visual disturbanceE Drowsiness or difficulty being arousedN Unequal sized pupils, or pupils that do notT respond to lightA Paralysis, numbness or loss of function overT one half of the bodyI Problems with balance Fluid flowing from eyes and/or mouthO Drunken behaviourN Fits, confusion or unconsciousness
INCR Intense headache, worse when lying flat and/or with physical exertionE Unequal or dilated pupilsA VomitingSE Weakness on one side of the bodyD Noisy, irregular breathing Irritable or aggressive behaviourICP
INCR Sedate and intubateE Nurse patient at 30 degree angle-aids venous drainageA Mild hyperventilation- keep pCO2S approx 4.5kPa- if allowed to fall lowerE this leads to vasoconstriction andD subsequent ischaemia Mild hypothermiaICP
INCR Surgical managementEA Burr holesS Evacuation of mass lesion +/-E craniectomyD Decompressive craniectomyICP