1. Head Injury
Dr Mohamed EL Hady.
Senior Neurosurgeon Specialist
K S H

2. Head Injury
44%
5%
21%
11%
6%
12% 1%
CARS
MOTORBIKES
DOMESTIC
WORK
SPORTS
OTHER CAUSES
UNKNOWN
Causes

3. Head Injury
 Any trauma to the
 Scalp
 Skull
 Brain
 Head trauma includes an alteration in
consciousness.

4.  Common major trauma
 4 million people experience head trauma
annually
 Severe head injury is most frequent cause of trauma death
 At Risk population
 Males 15-24 males 2x as likely as women
 Infants
 Young Children
 Elderly
Head
Injuries

5. Head Trauma
 Usually signifies craniocerebral trauma
 Includes alteration in consciousness
 High potential for poor outcome
 Death at injury
 Death within 2 hours after injury
 Death 3 weeks after injury

6. Consciousness
 State depends on intact cerebral
hemispheres
 Reticular activating system (RAS) in the brain
stem midbrain hypothalamus and thalamus
 Impairment on conscious level occurs due to
any lesions in the cerebral hemispheres or in
the (RAS)

7. RAS is located in
brain stem
RAS

8. Unconsciousness
 An abnormal state in which patient is
unaware of self or environment
 Can be for very short time to long term coma
 Care is designed to
 Determine the cause
 Maintain bodily functions
 Support vital functions
 Protect patient from injury

9. Different Types of Injury
Head Injury
Cranial Injury
Brain Injury

10. Head Injuries
Scalp wound
• Highly vascular, bleeds briskly
 Shock: child may develop
 Shock: adult another cause
• Management
 No unstable fracture:
direct pressure, dressings
 Unstable fracture: dressings, avoid
direct pressure
10Head Trauma -

11. Skull fracture
• Linear nondisplaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Management
• Dressing, avoid excess pressure
• Before operating
Head Injuries
11Head Trauma -

12. Cranial Injury
 Trauma must be extreme to cause fracture
 Linear
 Depressed
 Open
 Impaled Object

13.  Basal Skull
 Unprotected
 Spaces weaken
structure
 Relatively
easier to fracture

14. Cranial Injury
 Basal Skull Fracture Signs
 Battle’s Signs
 Retroauricular Ecchymosis
 Associated with fracture of
auditory canal and lower
areas of skull
 Raccoon Eyes
 Bilateral Periorbital
Ecchymosis
 Associated with orbital
fractures

15. Basilar Skull Fracture
Battle’s sign Raccoon eyes
15Head Trauma -

16. Raccoon eyes

17. Cranial Injury
 Basilar Skull Fracture
 May tear dura
 Permit CSF to drain
through an external
passageway
 May mediate rise of ICP
 Evaluate for“Halo” sign

18. Mechanism of injury
Non- missile or closed head injury
Acceleration – decelaration
Coup - counter coup

19. 191919
Acceleration
o Direct blow to the head
o Skull moves away from force
o Brain rapidly accelerates from stationary to
in- motion state causing cellular damage
Acceleration
19

20. 202020
Deceleration
o Head impacts to a stationary object (e.g., car
windshield)
o Moving skull stops motion almost immediately
o However, brain, floating in
cerebral spinal fluid (CSF),
briefly continues moving
in skull towards direction
of impact, resulting in
significant forces that
damage cells
Deceleration
20

21. 212121
Coup/Contracoup
Injury resulting from
rapid, violent
movement of brain is
called coup and
contracoup. This action
is also referred to as a
cerebral contusion.
o Coup: an injury
occurring directly
beneath the skull
at the area of
impact
o Contracoup:
injury occurs on
the opposite side
of the area that
was impacted
Coup injury
Contracoup
injury
21

22. Direct Brain Injury Types
 Coup
 Injury at site of
impact
 Contrecoup
 Injury on
opposite side
from impact

23. Mechanism of injury
Missile or penetrating
injuries

24. Crainial Injuries
Penetrating trauma
24Head Trauma -
Bullet fragments

26. Head Trauma - 26
Forces that cause skull fracture
can also cause brain injury.

27. Brain Injury
 As defined by the National Head Injury
Foundation
 “a traumatic insult to the brain capable of
producing physical , intellectual, emotional,
social and vocational changes.”

28. Focal brain injury
Brain contusion
Bruises on the brain

29. Brain contusion
 Contusion – bruising of brain tissue
 Has area of necrosis infarction and
hemorrhage
 Often from coup - contrecoup injury
 Seizures are common after contusion

30. Focal brain injury
•Blood between skull and
duramater
•Arterial bleed
•period of lucency
•relatively uncommon
•present in 1% of all
head-injured patients
Epidural hematoma

31. Focal brain injury
 Epidural hematoma
 Comes from bleeding between dura and inner
surface of the skull
 Will be unconscious, then awake, and then
deteriorate ( lucid interval )
 Headache, nausea and vomiting
 Needs surgical intervention to prevent brain
herniation and death

33. Focal brain injury
Subdural hematoma
> Between the dura mater and the piaarachnoid mater
> Occurring in approximately 30% of severe head injuries

34. Subdural Hematoma
- - - Usually bleeding is from veins, so bleeding is
GENERALLY slower than epidurals
 CAN be from arteries and these require
IMMEDIATE removal
 Administration of anticoagulants is one of the
causes of CHRONIC TYPES esp. in the
elderly.

36. Focal brain injury
Intracerebral hematoma
Can even appear 24 hours
following initial insult

37. Traumatic Subarachnoid Hemorrhage
 Most common CT finding in moderate to severe
TBI
 If isolated head injury, may present with
headache, photophobia and meningismus
 The outcome depends on the Size of bleed
 Timing of CT
 Nimodipine reduces death and disability by 55%

38. Traumatic Subarachnoid Hemorrhage

39. Brain Injury
Response to injury
• Swelling of brain
 Vasodilatation with increased blood volume
 Increased ICP
• Decreased blood flow to brain
 Perfusion decreases
 Cerebral ischemia ( hypoxia)
39Head Trauma -

41. Hurgada Red Sea Egypt

42.  Cushing’s Reflex
 Increased BP
 Bradycardia
 Irregular respirations
Signs & Symptoms
of Brain Injury
Vomiting
 Without nausea
 Projectile
Body temperature
changes
Changes in pupil
reactivity
Decorticate posturing

43.  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

44. Minor Head Trauma
 Concussion –patient may not lose
consciousness
 Will be a brief change in LOC, patient may
not remember the event and will have
headache
 Post-concussion syndrome is 2 weeks to 2
months after injury

45. Post Concussion Syndrome
 Persistent headache
 Lethargy
 Personality changes
 Short attention span
 Decreased short-term memory
 When patient is discharged after concussion
nurse should instruct family on what to watch
for and when to call Dr.

46. Clinical Manifestations of head injury
 Change in level of consciousness is the
most sensitive and important indicator of
neuro status
 May be pronounced or subtle
 Early signs may be nonspecific: restlessness,
irritability, generalized lethargy

47. Clinical Manifestations
 Headache
 From compression on the walls of cranial nerves,
arteries and veins
 Worse in the morning
 Straining and movement makes worse

48. Clinical Manifestations
 Vomiting
 NOT preceded by nausea- “unexpected”
 May be projectile

49. Clinical Manifestations
 Ocular signs
 Pupil changes are from pressure on third cranial
nerve
 Pupils become sluggish, unequal. This is
because of brain shift. May also be pressure on
other cranial nerves

50. Clinical Manifestations
 Decrease in motor function
 May have hemi paresis or hemiplegia
 May see posturing – either decorticate or
decerebrate
 Decerebrate – more serious from damage in
midbrain and brainstem
 Decorticate – from interruption of voluntary motor
tracts

51. Decerebrated and Decorticted

52. Diagnostic Tests
 CT
 MRI
 Transcranial Doppler studies
 Looking for vasospasm
 EEG
 No lumbar puncture if there is IICP because sudden
release of pressure can cause brain to herniate
 ABG’s – keep O2 at 100% and PCO2 as related to
ICP (25-35)

53. Diagnostic Tests
 Cervical spine x-ray
 You must see from 1 – 7 to see that they have no
injury
 Glasgow Coma Scale (GCS)

54. Glasgow coma scale
 First described in 1974 by Graham Teasdale
and Bryan J. Jennett
Lancet 1974, 2:81

55. Glascow Coma Scale
 Used to document assessment in three areas
 Eyes opening
 Verbal response
 Motor response
 Normal is 15 and less than 8 indicates coma

56. Glasgow coma scale

57. Minor Head Injury: 13-15
Moderate Head Injury: 9-12
Severe Head Injury (Coma): <= 8
Categorize of head injury

58. Other Assessment
 Assess bodily function including
respiratory,and circulatory
 Pupil checks – are pupils equal and how they
react to light
 Extremity strength
 Corneal reflex test

59. Alexandria Egypt

60. Principles of emergency management
 First priority is -
 Ventilation
 Circulation
 Stabilize cervical spine
 Limited time for initial evaluation of neurological
status
 Treatment of hemorrhagic shock takes
precedence over neurosurgical procedures

61. Emergency Management-Initial
 Airway
 Stabilize cervical spine
 Oxygen administration
 IV access (2 large bore catheters), LR or NS
 Control external bleeding with pressure
 Assess for rhinorrhea, otorrhea, scalp
wounds
 Remove clothing

62. Secondary Trauma Survey
 After patient relatively stable
 Look for coexisting other organ injuries
 Complete neurological examination
 Severity of head injury classified by GCS
score.

63. Drug Therapy
 Mannitol – Rapid short acting diuretic that
decreases ICP. Decreases total brain water
content
 Watch fluids and electrolytes closely
 Don’t give in cases of renal failure or if serum
osmolality increased

64. Drug Therapy
 Barbiturates – causes decrease in
metabolism and ICP. Causes reduction in
cerebral edema and blood flow to brain.
 Watch for hangover effects and drowsiness. Side
effects make it harder to check LOC. Watch for
constipation – do not want patient straining.
Skeletal muscle paralyses may be used (Pavulon)
Antiseizure drugs - Dilantin

65. management
 Treatment principles
 Prevent secondary injury in the brain
 Timely diagnosis
 Surgery if necessary
 Craniotomy
 Craniectomy
 Cranioplasty
 Burr-hole

66. Nutrition
 Patient need higher amounts of glucose to
survive.
 Will need nutritional support quickly.
 Watch sodium if on Mannitol – may need to
give additional salt.
 Also may need additional free water if
dehydrated

67. Nutrition
 Fluid balance is controversial
 Do not want too dry
 Keep normavolemic
 Give saline either .45% or normal saline – not
glucose to help prevent additional cerebral
edema

68. Laboratory Work
 ABGs regularly
 Electrolytes daily

69. Rehab
 Most head trauma requires rehab
 Some rehab units do coma management
 Patient may have trouble swallowing and
need speech therapy
 Patient may agitate easily and act out
sexually
 May be a flight risk and have to be in a
locked ward until passes through the
agitation phase

70. Elderly
 At risk for head trauma from falls
 Be alert if patient has fallen and is taking
anticoagullants