Presentation by Dept of Surgery Eko Hospitals, Ikeja, Lagos Nigeria on the 1st of July 2015. Prepared by Dr. Ajayi Babajide (Junior Resident Family Medicine.)

1. HEAD INJURY.
1

2.  Introduction
 Epidemiology
 Aetiology
 Classification
 Management
 Complications
 Take home points
2

3. Head injury can be defined as trauma to the
brain and/or its coverings from an
externally applied mechanical force.
The terms head injury and traumatic brain
injury are used interchangeably in
literature.
3

4. • Head injury data are difficult to compare
internationally for multiple reasons, including
inconsistencies and complexities of
diagnostic coding and inclusion criteria.
• However, it is generally found that trauma is
the fourth most common cause of death in
Nigeria (CDC-2011)
4

5. Top 10 Causes of Death in Nigeria.
(Source: CDC 2011)
1. Malaria 20%
2. Lower Respiratory Infections 19%
3. HIV 9%
4. Road Injuries 5%
5. Diarrheal Diseases 5%
6. Protein-Energy Malnutrition 4%
7. Cancer 3%
8. Meningitis 3%
9. Stroke 3%
10. Tuberculosis 2% 5

6. 6

7. • AGE: The Incidence is highest in active males
in the third decade of life (i.e. btw ages 21-30)
Approximately half of the patients admitted
to a hospital for head injury are aged 24 years
or younger.
• SEX: Men are nearly twice as likely to be
hospitalized with a brain injury than women.
7

8. 8

9.  Road traffic Accidents
 Falls Outside or inside the home, this is
common with those that are above 50
years.
 Missile or Gun shot injuries.
 Assaults or Civilian violence
 Sport injuries- Foot ball, polo games, base
ball, skating.
 Industrial accidents-Mishaps while
operating machines.
9

10. • Motor vehicle and motorcycle-related
accidents account for almost half of the
cases of head injuries, and deserve special
mention in this regard.
10

11. • Anatomical (Scalp, Skull and Brain)
• Closed or Open.
• Diffuse or Focal.
• Coup or contrecoup.
• Mild, Moderate or Severe.
• Non-haemorrhagic or Haemorrhagic
(extradural,subdural,subarachnoid
,intraparenchymal or intraventricular).
• Concussion,Contusion or Diffuse axonal
• Primary or Secondary 11

12.  SCALP INJURY:
Highly vascularised and bleeds profusely
 SKULL INJURY:
Fractures to cranium and the face may be
severe enough as to cause injury to the
brain.
 BRAIN INJURY:
Coup and contrecoup
12

13. 13

14.  Scalp
Laceration
Subgaleal haemataoma.
14

15.  Skull
Fracture:
• Simple or Compound.
• Linear or Comminuted.
• Depressed.
• Base of Skull.
15

16. 16

17.  Cerebrum (Traumatic Brain Injury)
▪ Concussion: a temporary brief change in mental
functions without damage to the structure of the brain.
▪ Contusion: bruises on the brain
▪ Laceration
17

18. The Glasgow Coma Scale
Has a minimum score of 3 and a maximum of 15
 Mild head injury------------------- (GCS 13-15)
 Moderate head injury-------------(GCS 9-12)
 Severe head injury-----------------(GCS 3-8)
 The scale was published in 1974 by GrahamTeasdale and Bryan
J. Jennett, professors of neurosurgery at the University of
Glasgow's Institute of Neurological Sciences
18

19.  Eye opening
• Spontaneous 4
• To speech 3
• To pain 2
• None 1
 BestVerbal Response
• Oriented 5
• Confused 4
• Inappropriate 3
• Incomprehensive 2
• None 1
Best Motor Response
• Obeys command 6
•Localizes pain 5
•Withdraws to pain 4
•Weak flexion 3
•Extends to Pain 2
•None 1
19

20. PrimaryTBI- is due to direct impact of trauma to
the brain.They include;
 Concussion :- a temporary brief change in
mental functions without damage to the
structure of the brain.
Contusion :- bruises on the brain
Lacerations :- when the tissue of the brain is
mechanically cut or torn.
20

21.  These result as a consequence of the complications
of the primary injury.
Secondary brain injury results from:
 Systemic hypotension,
 Hypoxia,
 Biochemical changes.
 Elevated Intracranial Pressure
(pressure effect of intracranial haematomas or brain swelling),
21

22.  Cranial compartment is rigid and has no room for
expansion
 Cranium and its constituents (blood, brain tissue
and CSF) are at a state of volume equilibrium.
 Thus an increase in the volume of one constituent
must be accompanied by a decrease in the volume
of the other two.
 Normal ICP can only be maintained via these
compensatory mechanism for volume less than 100-
120mls
22

23.  Before arrival at the hospital.
 On arrival at the hospital.
• Initial clinical evaluation and resuscitation: involves
a thorough systemic trauma evaluation and
stabilization process referred to as the advanced
trauma life support (ATLS) guidelines.
• After patient has been resuscitated and stabilized,
patient is then transported to an adequately equipped
hospital where attention may then be directed to a
focused head injury evaluation.
23

24.  General preventive measures are the only
way to avoid initial head injury.
 Hence the major concern in managing head
injury patients is the early detection of the
primary head injury and prevention of
secondary brain injuries.
 Quick history of the mechanism of injury
 Proper classification of the injury
 Find out if it is an isolated head injury case or
if patient has multiple injuries.
24

25.  First responders should immediately institute
the ATLS Protocols.
 Avoid moving the patient if at all possible
 A--------secure and preserving the AIRWAY,
 B------- maintain and supporting BREATHING
 C------- maintain the CIRCULATION
 D------- Assess level of DISABILITY
 E---------EXPOSURE
25

26.  Airway
 Remove any Foreign bodies in the airways
▪ Finger sweep
 Jaw thrust and chin lift
 Oropharyngeal airways, LMA
 Surgical cricothyroidectomy
 Endotracheal intubation
26

27.  Breathing
 Check for life threateninig conditions
 Tension pneumothorax
 Massive haemothorax
 Open pneumothorax
 Cardiac tamponade
 Resuscitation with supplemental oxygen
27

28.  Control haemorrhage
 Manual pressure
 Haemostats
 2 large-caliber iv catheter
 Use of Crystalloids/Blood
28

29.  Semi rigid/rigid collars,
 Side head supports and strappings
 Whole spine is immobilized in a neutral
position on a firm surface and the patients
whole body is transported as in one unit
without flexing the spinal column.
LOG ROLLING!!!!
29

30. 30

31.  Assessment of the level of consciousness in
the AVPU scale
 Alert
 Voice----------elicits response
 Pain-----------elicits response
 Unresponsive
 GCS
 Pupils size, equality and reaction
31

32.  Unclothe patient
 Prevent hypothermia
 Warm blanket
 Warm iv fluids
32

33.  Promptly transport people with suspected
TBI directly to a centre with a trauma team.
 Ideally in all cases, stand-by calls should be
made to the destination emergency
department (ED) for all patients particularly
those with GCS<8 and/or polytraumatization.
33

34.  Care of patients with CNS injuries is a
multidisciplinary endeavor.
 Paramedics, emergency medicine specialists,
trauma specialists, neurosurgeons,
neurointensivists,
neuroradiologists, and an array of highly
specialized nursing and technical staff are all
integral to succesful management.
34

35. The trauma team leader
 Coordinates life support (directs primary & secondary
survey)
 Assures priorities of diagnosis and defines order of
therapies
 Makes decisions regarding appropriate consultations,
medications, investigations and the need for surgical
intervention
 Ensures the trauma documentation is complete.
 It is essential that the team leader stands back from
the resucitation to coordinate and should NOT be
involved in clinical procedures
35

36.  GENERAL PRIORITIES:
 Maintain Airway
 Assess integrity of C-spine & immobilise
 Arrest Haemorrhage in scalp lacerations
 Assess Glasgow Coma Scale
 Assess Pupillary size
 Assess muscle tone, power and reflexes
 Assess sensation
 Do relevant X-Rays, CT scan
36

37. Things a quick history should elicit
include:-
 Mechanism of injury
 Loss of consciousness
 Presence of lucid intervals
 Altered consciousness
 Bleeding from lacerations
 Bleeding from orifices
 Rhinorrhea/Otorrhea
 Seizures
 Vomiting
37

38.  Inability to remember the cause of the injury or
events that occurred Immediately before or up
to 24 hours after
 Confusion and disorientation
 Difficulty remembering new information
 Headache
 Dizziness
 Blurry vision
 Nausea and vomiting
 Ringing in the ears
 Trouble speaking coherently
 Changes in emotions or sleep patterns
38

39.  The Glasgow Coma Scale (GCS) is the
mainstay for rapid neurologic assessment in
acute head injury. (Recall slides 17 & 18)
 Next a quick but thorough general examination
which should also include all obvious injuries
39

40.  Examine for signs of external trauma.
Bruising or bleeding on the head and scalp
and blood in the ear canal or behind the
tympanic membranes may be clues to occult
brain injuries.
 Also consider coexistent cervical spine and
other systemic injuries.
40

41. 41
Seen in fracture base of skull.

42. 42

43. Indication of Basilar skull fracture.
43

44. 44

45.  Anosmia (caused by the shearing of the olfactory
(CN I) nerves at the cribriform plate.
 Pupillary reactivity +/-Anisocoria
▪ A unilaterally dilated pupil with or without evidence of
ipsilateral cranial nerve (CN) III paralysis, such as ptosis
or impaired ocular motility, may indicate impending
herniation.
 CNVI (abducens) palsies may indicate raised
intracranial pressure.
 CNVII (facial)palsy, particularly in association with
decreased hearing, may indicate a fracture of the
temporal bone.
45

46.  Focal motor findings may be manifestations
of a localized contusion or, more ominously,
an early herniation syndrome.
 Flexor or extensor posturing
▪ extensive intracranial pathology or
▪ raised intracranial pressure. In the chronic phase,
 Spasticity, akinesia rigidity, tremors and dystonia
may also be present.
46

47.  Aphasia
 no ability to retain new information.
▪ Anterograde amnesia
47

48.  Laboratory Studies
 PCV/FBC
 E/U/Cr
 Arterial blood Gases
 Alcohol level
 Drug screens
 O2 Spirometry
 Imaging Studies
 Skull and cervical spineXrays:
 CT scanning. Skull and c- spine
48

49. • ComputerizedTomography Scanning:
• The standard CT scan for the evaluation of acute head
injury is a non contrast scan that spans from the base of
the occiput to the top of the vertex in 5-mm increments.
49

50.  Extradural haematoma-biconvex,
50

51.  Subdural-crescent shaped. (Hyperdense)
51

52.  Subarachnoid-filling of gyri over convex brain
surfaces. (hyperintense lesion)
52

53.  Wide bore intravenous access
 Need to Catheterise patients
 Oxygen therapy
53

54.  Mild head injuries :analgesics and close
monitoring for potential complications such as
intracranial bleeding.
 Moderate and Severe head injuries:There is
significant secondary injury :
 Prevention of hypoxia: Oxygen therapy
 Maintenance of perfusion: Ringer’s lactate Normal
saline, blood transfusions when indicated.
 Control of elevated intracranial pressure. Mannitol,
hyperventilation
54

55.  Monitoring of blood pressure: vassopressors
 Seizures: anticonvulsants
 Agitation:Paralytics,sedation.
 Nutrition:Enteral or parenteral feeding.
 Correction of dyselectrolytaemia:
Hyponatramia, Hypomagnesaesemia.
55

56.  Insomnia
 Cognitive decline
 Posttraumatic headache
 Posttraumatic depression
 Posttraumatic seizures
 Hydrocephalus
 Deep vein thrombosis
56

57.  Posttraumatic seizures
 Hydrocephalus
 Spasticity
 Gastrointestinal complications: Cushing’s
ulcers.
 Gait abnormalities
57

58.  A putative diagnosis of mild head injury does
not necessarily mean a favourable outcome.
 80% of patients with mild head injury recover
completely.
 Patients could develop Alzheimer’s disease
subsequently.
 Adequate follow up is essential.
58

59.  Head injured patients need not die at the site of accident
 Head injured patients should be carefully assessed in order
to categorise them.The more severely injured should be
stabilised and referred as soon as possible.
 Multidisciplinary approach is key in the management of the
head injured patient.
 Improved medical facilities coupled with skilled first contact
physician and appropriate public awareness will improve
prognosis.
59

60. 60

61. THANKYOU.
61

62.  Orledge JD, Pepe PE. Out-of-hospital spinal immobilization: is it really necessary?. Acad Emerg
Med. 1998 Mar. 5(3):203-4. [Medline].
 Hadley MN,Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, et al. Guidelines for
the management of acute cervical spine and spinal cord injuries. Clin Neurosurg. 2002. 49:407-98.
[Medline].
 Lockey D, Davies G, CoatsT. Survival of trauma patients who have prehospital tracheal intubation
without anaesthesia or muscle relaxants: observational study. BMJ. 2001 Jul 21. 323(7305):141.
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intubation for severe head injury in children: a reappraisal. Semin Pediatr Surg. 2001 Feb. 10(1):3-
6. [Medline].
 Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with
severe head injury.Trauma Research and Education Foundation of San Diego. Arch Surg. 1997 Jun.
132(6):592-7. [Medline].
 Gabriel EJ, Ghajar J, Jagoda A, Pons PT, ScaleaT,Walters BC. Guidelines for prehospital
management of traumatic brain injury. J Neurotrauma. 2002 Jan. 19(1):111-74. [Medline].
 Stern SA, Zink BJ, Mertz M,Wang X, Dronen SC. Effect of initially limited resuscitation in a
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 Rotstein OD. Novel strategies for immunomodulation after trauma: revisiting hypertonic saline as
a resuscitation strategy for hemorrhagic shock.
62

63.  RESUSCITATION
 To reverse immediately life-threatening situations and maximize patient survival
 TREATMENT PRIORITY
 NECCESSARY PROCEDURE
 Airway
 Jaw thrust/chin lift/
 Suction
 Intubation
 Cricothyroidotomy
 ( with protection of C-spine )
 Breathing/Ventilation/oxygenation
 Chest needle decompression
 Tube thoracostomy
 Supplemental oxygen
 Seal open pneumothorax
 Circulation/hemorrhage control
 IV line/ central line
 Venous cutdown
 Fluid resuscitation/Blood transfusion
 Thorocostomy for massive hemothorax
 Pericardiocentesis for cardiac tamponade
 Disability
 Burr holes for trans-tentorial herniation
 IV mannitol
 Exposure/Environment
 Warmed crystalloid fluid
 Temperature
63