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Head injury( Diagnosis/symptoms/investigation/Treatment)
- 1. Presentors : Dr. Cimona Shrestha Dr. Jiwan Pandey (Intern in SBH) Head Injury
- 2. Introduction • Head Injury : trauma to head may or may not include injury to brain. • Craniocerebral injury : all injuries in which an injury to the cranium occurs where the brain also participates in injury
- 3. Causes
- 6. Classification of brain injury Based on mechanism : primary and secondary Based on severity :Glasgow coma scale Based on Patho-anatomical findings.
- 8. Classification FOCAL INJURIES DIFFUSE INJURIES Contusions Fracture Coup Contrecoup Herniation Intermediate Gliding Concussion Diffuse Axonal Injury Extra axial Epidural Subdural subarachnoid Intra-axial Intracerebral Intraventricular Hemorrhage Accrding to anatomic consideration Scalp laceration Skull Fracture Brain Injury
- 10. Grading according to GCS Injury Category GCS score Minimal 15, no LOC or amnesia Mild 14, or 15 with amnesia or brief LOC or impaired alertness or memory Moderate 9-13, or LOC for more then 5min or focal neurological deficit Severe 5-8 Critical 3-4
- 11. Scalp laceration • Minor type of head trauma • Scalp highly vascular leading to profuse bleeding • Infection: major complication
- 12. Skull fractures
- 13. Hemorrhage in Head Injury Extra axial hemorrhage Intra axial hemorrhage •Epidural •Subdural •Subarachnoid •Intracerebral mostly medical cause:HTN,Embolism •Intraventicular mostly secodary phenomenon when subarchnoid hemorrhage ruptures
- 14. Epidural Subdural Location Between skull and outer endosteal layer of dura matter Between dura and arachnoid matter Involved vessels Middle meningeal Bridging veinsFrontal Anterior ethmoidal Occipetal Transverse or sigmoid sinus vertex Superior saggital sinus Temporoparietal
- 15. Cause Trauma most common cause Severe trauma to head, Acceleration deceleration injury Risk Factors : Elderly, patients on anti coagulants, alcoholics Clinical features LOC >>>Lucid Interval >>LOC Signs of raised ICP Signs of Cerebral compression/Herniation Headache, Decreased level of conscioucness Radiology
- 16. Subdural hematoma Acute <3days Subacute 3-21 days Chronic >21days Composition Clotted blood Clotted blood and fluid Fluid Radiology
- 17. Subarachnoid Hemorrhage • Clinical features : – Explosive or thunderclap headache/ “worst headache of my life” – Nausea, vomiting and decreased LOC or coma – Signs of meningeal irritation
- 18. Concussion • usually the result of acceleration-deceleration • Mild concussions amnesia may be present Retrograde (after the injury) antegrade (before the injury) • Severe concussion Loss of consiousness symptoms as headache, fatigue, memory or learning deficits, and dizziness 3 months after injury
- 20. Contusion • Subpial extravasation of blood and swelling of affected area Types • Fracture contusion: direct contact injuries and underlying skull fracture • Herniation contusion : at area where temporal lobe or cerebellar tonsil make contact with tentorium or foramen magnum
- 21. Coup contusion: occur at site of impact in absence of fracture Countercoup contusion : diameterically opposite to point of impact
- 22. APPROACH TO HEAD INJURY
- 23. History Analysing symptoms Emergency Management Secondary survey Primary survey Investigation Management Conservative management Surgical management
- 24. History • Type of accident • Level of consciousness • Amnesia • Vomiting • Seizures • Swelling and pain in head • Watery discharge from ear, nose and mouth Past history : similar head injury Hypertension Personal History : Alcohol and other drug intoxication Primary survey • Check pupil size and response to light • Glasgow Coma score • Check any focal neurological deficit • Check blood sugar for hypoglycemia • Ensure adequate oxygenation and circulation
- 25. History Analysing symptoms Emergency Management Secondary survey Primary survey Investigation Management Conservative management Surgical management
- 26. 1. Airway Intubate if GCS<8 If patient is unresponsive 2.Breathing prevent hypoxia Maintain PCO2 at normal level(>35mm Hg) Obtain CXR as soon as possible Check ABG 3.Circulation control bleeding Fluid resusitation with isotonic saline prevent hypotension 4.Analgesia Morphine avoided NSAIDs can be used
- 27. History Analysing symptoms Emergency Management Secondary survey Primary survey Investigation Management Conservative management Surgical management
- 28. Secondary survey
- 30. Features of skull base fracture Battle’s sign Racoon eyes
- 32. Eye Examination Dysconjugate gaze Conjunctival hemorrhage
- 34. Neck and spine • Cervical spine fracture • Peripheral nerve examination – Tone, power, reflex, sensation • Per-rectal examination – Anal tone – Sensation – Anal wink • Priapism Cervical spine fracture
- 35. Investigations
- 36. • Investigations Cervical spine x-rays: to rule out c-spine injuries Diagnostic CT- scan of head :NICE guidelines MRI Lumbar puncture for subarachnoid hemorrhage but in case of increased ICP AVOIDED as herniation can occur ABG for monitoring ICP Monitoring Fig ICP Monitoring methods
- 37. NICE guidelines for CT-head in Head Injury • GCS<13 at any point • GCS=14 at 2 hours • Focal Neurological deficit • Suspected open,depressed or basal skull fracture • Seizure • Vomiting>1episode Urgent CT-head Scan if none of the above but • Age>65 yrs • Coagulopathy • Dangerous mechanism of injury • Antegrade amnesia >30min
- 38. S History Analysing symptoms Emergency Management Secondary survey Primary survey Investigation Management Discharge in case of minor and mild head injury Conservative management Surgical management
- 39. Discharge criteria in minor and mild head injury • GCS 15/15 with no focal neurological deficits • Normal CT brain • Patient not under influence of alcohol or drugs • Accompanied by responsible adult • Verbal and written advice : seek medical attention if persistent /worsening headache persistent vomiting visual disturbance limb weakness or numbness
- 40. Conservative management prevent raised ICP Head elevation: head raised to 30-45 deg to enhance venous drainage reducing intracranial blood vol and ICP Neck in neutral positon, collar if placed fix properly Blood pressure: monitor and maintain by fluid management Temperature: hyperpyrexia inrease cerebral metabolic rate compromising Optimal oxygenation: avoid hypoxia or hyperventilation Monitor glucose : often hyperglycemic ..cerebral edema ..increased anerobic glycolysis ..lactic acidosis
- 41. Conservative management Drugs • Mannitol and Furesemide removes water from brain by creating more osmotic diffusion gradient avoid in derranged RFT • Antiepileptics to prevent fits eg. Fosphenytoin • Antipyretics to avoid hyperthermia eg. Acetamaminophene • Barbiturates and propofol : lower ICP through vasoconstriction + suppression of cerebral metabolism
- 42. Surgical intervention - Acute epidural haematoma - Acute subdural haematom -Traumatic parenchymal lesion -Posterior fossa mass lesions -Depressed cranial fractures
- 43. Surgical interventions • Evacuation via Burr-hole • Craniotomy: bone flap temporarily removed from skull to access brain • Cranectomy: skull flap not replaced immediately • Cranioplasty : surgical repair of defect of deformity of skull Fig burr hole
- 44. Rehabilitation • Nutrition • Bowel and bladder management • Seizure disorders • Familly participation and education
- 45. Thank you…