7. Epidemiology
• Incidence: ∼ 800/100,000
• Age: especially children 0–4 years, teenagers
and young adults 15–24 years, and adults > 65
years
• Sex: ♂ > ♀
8. Etiology
Blunt head injury (common)
Falls
Motor vehicle
accidents
Contact sports
assaults
Penetrating head injury (less
common)
High-velocity missile injury
Low-velocity nonmissile
injury
9. Site of Injury
•Scalp injury
•Skull injury
•Intracranial vascular injury
• Brain injury
10.
11. Scalp laceration
- The most common minor type of head trauma
- Scalp is highly vascular → profuse bleeding
- Major complication is infection
12. Head Injury fractures
Facial fractures
Linear Skull Fracture
Depressed Skull Fracture
Basal Skull Fracture
15. • which are caused from wide blunt skull injury
• the most common skull fracture
• break in the continuity of bone without
alteration of relationship of parts
• Needs no treatment and heals by itself ,
Patient admitted for observation
17. • Depression in skull
• Often associated with brain injury
• Bone fragments can tear the dura
• Can cause infection
• Craniotomy is required to elevate the fracture,
repair dural disruption, and obtain
hemostasis.
18. Basilar skull fractures
• A skull fracture that involves at least one of the
bones that make up the skull base .
19. Anterior basilar skull fracture
• CSF rhinorrhea
• Raccoon eyes
• Palsies of cranial nerves
• I, V, VI, VII, and/or VIII
30. Epidural hematoma
• Results from bleeding between the dura and
the inner surface of the skull
• MC type of traumatic Intracranial bleed, rarely
occurs spontaneously
• A neurologic emergency
31. Epidural hematoma
• Source of Bleed:
Temperoparietal locus (most likely) -Middle meningeal
artery
Frontal locus - anterior ethmoidal artery
Occipital locus- transverse or sigmoid
sinuses Vertex locus - superior sagittal sinus
• Clinical Features:
LOC>>> Lucid Interval >> unconsciousness
s/s of raised ICP Focal neurological deficit s/s of cerebral
herniation
32.
33. Subdural hematoma
– Occurs from bleeding between the dura mater
and arachnoid layer of the meningeal covering of
the brain
– Source of bleed: Bridging veins;
– Cause: Acceleration-deceleration injury, direct
trauma ,
– Risk factors: Elderly, dementia, alcoholics, shaken
baby syndrome, pts on anticoagulants
34. Subdural hematoma
- Acute subdural hematoma(<72hrs(
• High mortality
• Associated with major direct trauma
Clinical Features:
Headache, fluctuating LOC, confusion, dilated
fixed pupil, deviated gaze .
CT scan: hyperdense.
35. Subdural hematoma
• Subacute subdural hematoma within 4-21
days
• Failure to regain consciousness may be an
indicator
CT scan: Isodense or hypodense
36. •Chronic subdural hematoma(>3wks(
• Develops over weeks or months after a
seemingly minor head injury, probably from
repeat minor bleeds
CT scan : hypodense
39. • Clinical Features:
• Explosive or thunderclap headache, “worst
headache of my life",
• nausea and vomiting, decreased LOC or coma,
• Signs of meningeal irritation
41. Intracerebral Hemorrhage (ICH
Two main types :
• Intraparencymal hemorrahge- ICH extending into
brain parenchyma; MCC- HTNsive vasculopathy
• Intra-ventricular hemorrhage- ICH extending into
ventricles; MCC –trauma. Causes: Hypertensive
vasculopathy (
70
-
80
(% ,Ruptured AVM
42. Intracerebral Hemorrhage (ICH)
• Clinical presentation:
o Rapidly progressive severe headache
o focal neurological deficits,
o nausea and vomiting,
o decreased level of consciousness.
43. • S/S depend site of hemorrhage:
–Basal ganglia/internal capsule -
hemiparesis, dysphasia
–Cerebellum
ataxia, vertigo
– Pons
cranial nerve deficits, coma
– Cerebral cortex
hemiparesis, hemisensory loss, hemianopsia,
dysphasia
45. Coup-contrecoup injury
• Coup injury: injury on the side of an
impact
• Contrecoup injury: additional injury
(typically a contusion) on the opposite
side of impact
49. Cerebral Contusion
• focal area of heterogeneous brain injury, varying
from a bruise to a focal area of necrosis
• maintains the integrity of the pia mater and
arachnoid layers associated with multiple micro-
hemorrhages, small vessel bleed into brain tissue
Lacerations
CT: heterogeneous lesion (mixed hemorrhagic,
necrotic, and edematous tissue) surrounded by
cerebral edema .
50. Contusion
bruise of the brain, and occurs when the force from
trauma is sufficient to cause breakdown of small
vessels and extravasation of blood into the brain.
Involve frontal, temporal and occipital lobes
54. Concussion
• head injury with a temporary loss of brain
function
• Cause: Sudden acceleration and deceleration
injury eg: Car accident, sports injury, bicycle
accident etc
57. Management
• Monitor for 24 hours
• CT scan if worsening symptoms
• Slow return to sports once free of symptoms
• Usually at least 1 week of no sports.
58. Post-concussion syndrome
• After days to weeks of first injury.
• Headache, dizziness, insomnia… etc
• Resolve spontaneously within 1 month .
59. Diffuse axonal injury (DAI)
• Widespread axonal damage occurring after a
mild, moderate, or severe TBI
• Seen in half the cases of head injury
• Process takes approximately 12-24 hours
60. Diffuse axonal injury (DAI):CT can be normal in
mild DAI; multiple punctate hyperdensities
indicating small hemorrhages typically at the
junction of gray and white matter, brainstem,
internal capsule, and corpus callosum .
Cerebral edema: compression of ventricles,
loss of defined sulci and gyri, and effacement
of basal cisterns .
61.
62.
63. Secondary brain injury
• indirect brain injury that results from
physiological changes triggered by acute CNS
trauma and/or its treatment measures that
affect ICP, oxygenation, blood pressure, etc.
65. Mx of high ICP
» Ventilate
» Aggressively treat hypotension with IV fluid boluses and vasopressors
» adequate analgesia
» muscle relaxants
» Mannitol 0.5-1 g/kg (2.5-5 ml/kg of 20% mannitol) by intravenous
infusion over 20 min
66. cont…
• Consider hypertonic saline (3-5mls/kg of 3% saline)
intravenous bolus (if given rapidly may drop BP)
• Phenytoin 20 mg/kg should be given to prevent early
post-traumatic seizures.
• Hyperthermia should be avoided (> 37.5°C). The head of
the bed should be elevated (without hip flexion.
68. Cingulate Herniation
The most common type,
Cingulate herniation can be caused when one
hemisphere swells and pushes the cingulate
gyrus by the falx cerebri. Cingulate herniation
is frequently believed to be a precursor to
other types of herniation.
69.
70. Uncal Herniation
• common subtype of cerebral herniation
following raised ICP Innermost part of the
temporal lobe, the uncus, can be squeezed so
much that it moves towards the tentorium
and puts pressure on the brainstem, most
notably the midbrain
• Clinical feature: fixed dilted pupil,
homonymous hemianopsia, hemiparesis.
76. Secondary survey
• Focused history
• AMPLE history
• Mechanism/time of injury
• Presence/duration of amnesia
• Presence of seizures/headache/ visual
disturbances
• Use of anticoagulant medication
• Vitals, SpO2
• ABCs
