Traumatic brain injury (TBI) is a major health problem in India, with over 1 million injuries and 200,000 deaths reported annually. The leading causes of TBI in India are road traffic accidents, which account for 60-70% of cases. Common types of TBI include concussions, skull fractures, and contusions. Initial treatment focuses on stabilizing the airway, breathing, and circulation, with diagnostic tests like CT scans used to further evaluate injuries. Management involves measures to reduce cerebral edema as well as medical therapies tailored to the specific injuries. Long-term rehabilitation is often needed to address physical, cognitive, and behavioral impairments resulting from TBI.

1. HEAD INJURY & MEDICAL
TREATMENT

2. Head injury-hidden epidemic
• Traumatic brain injury (TBI) / head
injury occurs when a sudden
trauma, such as a blow to the head,
causes damage to the brain.
• Such injuries can result in impaired
physical, cognitive, emotional, and
behavioral functioning.

3. INDIAN SCENARIO
• Major health problem in India due to greater growth and
development in terms of motorization, urbanization.
• It is estimated that nearly 1 million persons are injured,
200,000 people die and nearly 1 million require rehabilitation
services every year in India.
• In India, 60%–70% of TBI results from Road Traffic Accidents
(RTA)
• It has been reported that India has the highest mortality rates
from RTA in the world, with 161,736 RTA deaths in 2010
Abhijit Das et al Neurology 79 November 20, 2012

4. Causes of head injury
• Automobile accidents, (Under age of 75)
• Falls (Above age of 75)
• Assaults/blows,
• Sports-related injuries,
• Explosive blasts

5. TYPES OF HEAD INJURY
• Scalp lacerations
• Skull fractures
• Minor Head Trauma: Concussion and post-concussion
syndrome
• Major Head Trauma: Cerebral contusion, Laceration
TBI review National Institute of Neurological Disorders and
Stroke National Institutes of Health

6. Skull fractures
• Linear Skull Fracture
• Depressed Skull Fracture
• Diastatic Skull Fracture
• Basal Skull Fracture
• Compound Skull Fracture
• Compound elevated Skull
Fracture
• Growing Skull Fracture

7. Skull fracture-contusion
• Skull fractures occur when the bone of the skull cracks or
breaks. A depressed skull fracture occurs when pieces of the
broken skull press into the tissue of the brain. A penetrating
skull fracture occurs when something pierces the skull, such
as a bullet, leaving a distinct and localized injury to brain
tissue.
• Skull fractures can cause bruising of brain tissue called a
contusion. A contusion is a distinct area of swollen brain
tissue mixed with blood released from broken blood vessels.
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS

8. concussion
• Concussion is the most
minor and the most
common type of TBI.
Technically, a concussion is
a short loss of
consciousness in response
to a head injury
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS

9. contrecop
• A contusion can also occur in response to shaking of the
brain back and forth within the confines of the skull, an
injury called “contrecoup.”
• This injury often occurs in car accidents after high-speed
stops and in shaken baby syndrome, a severe form of
head injury that occurs when a baby is shaken forcibly
enough to cause the brain to bounce against the skull.
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS

10. Hematoma
• Damage to a major blood vessel in the head can cause a
hematoma, or heavy bleeding into or around the brain.
• Three types of hematomas can cause brain damage.
1. Epidural hematoma involves bleeding into the area between the
skull and the dura.
2. In subdural hematoma, bleeding is confined to the area between
the dura and the arachnoid membrane.
3. Bleeding within the brain itself is called intracerebral hematoma.
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS

11. SYMPTOMS OF POST-
CONCUSSION SYNDROME
• The most common
symptoms after head
injury are known as
post-concussion
syndrome (PCS).

12. Diagnostic measure
• Skull and neck X-rays
• CT scan
• MRI
• Intracranial pressure monitoring
• Electroencephalography(EEG)
• Nerve conduction velocity (NCV)
• Electronystagmography

13. Complications
• Coma
• Paralysis
• Chronic headache
• Loss/change in sensation,
hearing, vision, taste or smell
• Paralysis
• Speech problem
• Seizure
• Death

14. Assessment after stabilization
As soon patient get stabilized, assess the patient’s condition by
measuring
• vital signs and reflexes and by performing a neurological
examination.
• Temperature, blood pressure, pulse, breathing rate, and pupil
size in response to light.
• The level of consciousness as assessed by the Glasgow Coma
Scale has been used to categorise the severity of a head injury
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS

15. Glasgow coma scale

16. Indications for referral to hospital
• GCS<15 at initial assessment
• ƒPost-traumatic seizure (generalised or focal)
• ƒFocal neurological signs
• ƒSigns of a skull fracture (including cerebrospinal fluid from nose or ears,
haemotympanum, boggy haematoma, post auricular or periorbital bruising)
• ƒLoss of consciousness
• ƒSevere and persistent headache
• ƒRepeated vomiting (two or more occasions)
• ƒPost-traumatic amnesia >5 minutes
• ƒRetrograde amnesia >30 minutes
• ƒHigh risk mechanism of injury (road traffic accident, significant fall)
• ƒCoagulopathy, whether drug-induced or otherwise.

17. Supportive Measures
• Endotracheal intubation for patients with decreased level of
consciousness and poor airway protection.
• Cautiously lower blood pressure to a MAP less than 130 mm Hg, but avoid
excessive hypotension.
• Rapidly stabilize vital signs, and simultaneously acquire emergent CT
scan.
• Maintain euvolemia, using normotonic rather than hypotonic fluids, to
maintain brain perfusion without exacerbating brain edema
• Avoid hyperthermia.
• Facilitate transfer to the operating room or ICU.
Harrison’s internal medicine 17th edition

18. Initial management
• A: airway
• B: breathing
• C: circulation
• D: dysfunction/disability
• E: external management
Harrison’s internal medicine 17th edition

19. Decrease cerebral edema
• Modest passive hyperventilation to reduce PaCO2
• Mannitol, 0.5-1.0 gm/kg slow iv push
• Furosemide 5-20 mg iv
• Elevate head 20-30 degrees, avoid any neck vein compression
• Sedate and paralyze if necessary with morphine and
vecuronium (struggling, coughing etc will elevate intracranial
pressure)
Harrison’s internal medicine 17th edition

20. Medical therapy
• Antihypertensives - reduce blood pressure to prevent exacerbation of intracerebral
hemorrhage in hypertensive encephalopathy. Eg Nicardipine, labetolol; CCB helps
to relieve vasospasm in SAH and decrease further damage
• Diuretics - Mannitol, CAI
• Anticonvulsants – reduce frequency of seizures and prophylaxis of seizures eg:
Fosphenytoin
• Antipyretics- to Rx fever and pain relief eg: Acetaminophene
• Antidote- VitK/FFP for warfarin overdose; protamine for heparin overdose
• Antacids- prophylaxis for Cushing’s gastric ulcer eg: Famotidin
• Glucorticoids may help reduce the head and neck ache caused by the irritative effect
of the subarachnoid blood.
Harrison’s internal medicine 17th edition

21. Diet plan
• Protein is used for almost all tissue repair of the body
• Those with head injury require 0.55 to 0.73 gm of protein
per pound of body weight
• Someone with a GCS of 4 to 5 needs 22.7 to 27.3 calories
per pound of body weight per day.
• Someone with a GCS of 6 to 7 needs 18.2 to 22.7 calories
• Those with less-severe injuries who have a GCS of 8 to 12
require 13.6 to 16 calories.

22. SAFETY TIPS
• Wear a seatbelt every time you drive or ride in a car.
• Wear a helmet while riding
• Make sure the surface on child’s playground is made of
shock-absorbing material
• Keep firearms and bullets stored in a locked cabinet when
not in use
Traumatic Brain Injury: Hope Through Research,” 2002,
NINDS