Head injury/TBI

UNIVERSITY OF GONDAR
COLLEGE OF MEDICINE AND HEALTH SCIENCES
SCHOOL OF NURSING
DEPARTMENT OF EMERGENCY AND CRITICAL CARE
NURSING
Surgical Emergency Seminar Presentation
Title: Head Injury/Trauma
By:
May/2021

Presentation Outline
 Definition
 Epidemiology of HI
 Types of HI
 Risk factors
 Causes of HI
 Pathophysiology
 Clinical manifestations
 Dx/investigations
 DDx
 Management
 Complications
2
8/9/2021
By: Asnake, Muhammed, Nega, &
Zemene (1st Yr MSc EMCCN students)

Objectives
After this presentation you will be able
to:
 List the Causes/risk factors of HI
 Describe types of HI
 Describe the pathophysiology/MOI of HI
 Discuss the clinical features of HI
 Describe the approach to a patient with HI
 Manage a patient with HI
 Dispose a patient with HI
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Head-Anatomy Overview
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Definition
 Head injury- is an injury of the SCALP, skull or
brain tissue ranges from a minor scalp laceration to
serious brain injury.
 Scalp
 Skull
 Meninges
Dura Mater
Arachnoid
Pia Mater
 Brain Tissue
 CSF and Blood
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Epidemiology
 Trauma is the leading cause of death in persons
< age 45, and head injury accounts for 50% of
these deaths.
 Head injury is the leading Killer in trauma.
 4 million people experience head trauma
annually(WHO).
 50% of all deaths from MVA/RTA.
 Male :Female-2:1
 Age-teenagers/children (1-19 yrs.) & older adult.
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8/9/2021

Risk factors for HI
 Intoxicants (alcohol and drugs).
 Lack of safety devices (seat belts, helmets)-MVC
 Elderly-Sensory deficits (hearing, sight, touch,
balance, motor, coordination & other
physiological/anatomical).
 Adverse environmental conditions (road,
weather/topography)
 Young adults
 Male gender
 Being epileptic/psychiatric illness
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8/9/2021

Causes of HI
 Motor vehicle crashes/RTA
 Falls- from>= 3m height
 Strike by objects/Assaults
 Penetrating/sharp impalements/objects
 Sport-related injuries
 Home/work-related injuries
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Pathophysiology/Mechanism of injury
9
Initial insult on the head
Mechanical damage/mass effect
Skull and parts of brain move against one another
Damage to BBB/CSF/Brain cells
Intracellular & extracellular fluid contents rise
Cerebral edema
Increase ICP
Decrease CPP
Decrease brain perfusion/ischemia-compression
Brain Herniation
Brain death
8/9/2021

Types of HI
Head injury can be classified based on:
The layers of the head/morphology
Scalp laceration, Skull #, & TBI
 Severity of Injury-GCS Score
-mild HI (TBI), moderate HI, severe HI
Site/location of injury-part of brain affected
-Focal/local
-Diffuse/generalized
Insult/Relation to traumatic event/time of
occurrence:
-Primary Brain Injury
-Secondary Brain Injury
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Type Cont…
SCALP Laceration
 Easily recognized minor type of head trauma.
 Since the SCALP is highly vascular profuse
bleeding may be present.
 Most scalp injuries are simple penetrating
injuries.
 Characterized by: swelling, pain, tenderness and
bleeding from the site of injury.
 Major complication is infection.
11
8/9/2021
Zemene (1st Yr MSc EMCCN
students)

Type Cont…
Skull fracture
Is a break in the continuity of the skull with or
without damage to the brain.
Simple (linear) skull # - break in the
continuity of skull without alteration of
relationship of parts.
Comminuted skull # - splintered type or
multiple fracture line/pieces/fragment.
Depressed skull # -the bones of the skull are
displaced downward vary from a slight
depression to an embedding within the brain
tissue.
Basilar skull #: A fracture of the base of the 12
8/9/2021

Type Cont…
Traumatic Brain Injury
Mild TBI- HI with a GCS score 13-15.
E.g.-SCALP laceration & cerebral
concussion.
Moderate TBI- HI with GCS score of 9-12
Severe TBI- HI with GCS of score of <=8.
-This classification dictates the workup and
ultimate disposition.
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Type Cont…
14
Focal Brain/Head injury
 Epidural hematoma (EDH)- most often occurs
as a result of bleeding from the middle meningeal
artery or after a blow to the head causes a skull
fracture.
 A lenti-form/biconvex/Lens shaped hematoma
forms that does not cross the suture lines.
 Characterized by a brief initial period of LOC, a
lucid interval lasting minutes to hours(2days),
and subsequent deterioration in neurologic
status due to increased ICP.
 Then severe headache, vomiting, drowsiness,
confusion, seizures, HTN, bradycardia and/or
hemiparesis may develop.
 Most urgent of all cases of cranial trauma.
8/9/2021

Type Cont…
 Subdural hematoma (SDH)- is caused by
bleeding from tearing of cortical bridging veins
in the subdural space. It is more common in
elderly patients with cerebral atrophy.
 Characterized by crescent shape/concavo-
convex hematoma.
 Cause: Acceleration-deceleration injury, direct
trauma.
 Types:
1. acute subdural hematoma
2. sub acute subdural hematoma
3. Chronic subdural hematoma
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Type Cont…
Acute subdural hematoma
 Occurs within 3 days from trauma (<72hrs).
 High mortality
 Associated with major direct trauma(Shearing
Forces)
 Characterized by: Headache, fluctuating LOC,
confusion, dilated fixed pupil.
 CT scan: hyper dense.
Sub acute subdural hematoma
 Occurs within 4-21 days of the injury
 Failure to regain consciousness may be an indicator.
 CT scan: Isodense
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16

Type Cont…
 Chronic subdural hematoma(>3wks)
 Develops over weeks or months after a
seemingly minor head injury, probably from
repeat minor bleeds. It is hypo dense on CT
scan.
8/9/2021
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Type Cont…
 Traumatic subarachnoid hemorrhage
- is caused by Tear of veins/arterioles in the
subarachnoid space mostly inter-
peduncular fossa.
- is usually has a benign/self-limiting.
• Sudden severe headache, “worst headache
of mylife.”
• Neck stiffness, photophobia & sometimes
fever.
• May have LOC/neurological deficit.
8/9/2021
By: Asnake, Mohammed, Nega, &
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Type Cont…
Cerebral contusions- are
bruise/hematomas in the brain most
commonly seen in the frontal, temporal, or
occipital regions. Affected areas include:-
• Basal ganglia
• Lobar regions
• Thalamus
• pons
• Cerebellum
• Other brainstem sites
8/9/2021
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Type Cont…
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Diffuse Brain/Head injury
 Concussion- is as a transient LOC/other
neurologic function that lasts for a few minutes(3-
15min) immediately after blunt head trauma in
the absence of findings on CT scan.
 Mild diffuse axonal injury.
- Symptoms include headache, sleep
disturbances, amnesia, and difficulty with
concentration.
- Multiple cerebral contusions-When contusions
occur at the site of the blunt force and on the
opposite side of the brain, they are known as
coup and contrecoup injuries, respectively.
8/9/2021

Type Cont…
 Diffuse axonal injury (DAI)- is due to
disruption of axonal fibers in the brain due
to shearing/tearing forces. characterized
by:
Immediate Coma/ persistent AMS in the
absence of a focal lesion on the CT scan.
Most severe of all primary brain lesions.
Autonomic dysfunction (i.e., increased BP,
increased temperature, sweating).
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Type Cont…
Primary brain injury
- Induced by mechanical force and occurs at the
moment of injury by 2 main mechanisms.
-An object striking the head and acceleration-
deceleration.
Secondary Brain injury
-Preventable occurs at some time after the
moment of impact/non-mechanical.
-it is superimpose injury on a brain already
affected by a mechanical injury.
-Subsequent or progressive brain damage
arising from events developing as a result of
primary brain injury.
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Type Cont…
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23
 2o injury Includes:- hypotension/hypoxia
-Seizure, Herniation, Ischemia/infarction
-decrease CPP/Increase ICP/Cerebral
edema
-Hypo/HYPERGLYCEMIA, Hydrocephalus
-hypo/hyperthermia, Brain death.

Type Cont…
Intracranial Pressure(ICP)
 Is the pressure of the brain contents within
the cranium.
 CPP=MAP-ICP
 10 mm Hg=Normal
 >20 mm Hg=Abnormal
 >40 mm Hg=Severe
 Sustained increased ICP leads to
decreased brain function and poor outcome
8/9/2021
Zemene (1st Yr MSc EMCCN students) 24

Type Cont…
25
Monro-Kellie doctrine hypothesis
 States that an increase in the volume of
one component inside the skull (brain,
blood, CSF) or addition of a new
component (hemorrhage, tumor) mandates
a compensatory decrease in other
components to maintain constant ICP.
8/9/2021

Type Cont…
8/9/2021
26
 Head injury  cerebral oedema  increased
ICP  cerebral arteries delivering oxygenated
blood require higher pressure to perfuse
swollen brain.

Type Cont…
Symptoms & signs of increased ICP
 Decrease LOC
 Headache, vomiting(projectile)
 Cushing’s Triad/Herniation syndrome:
-Bradycardia
-Hypertension
-Tachypnea, bradypnea then irregular breathing
 Pupillary changes/unequal pupils
 A significantly dilated pupil, which may be
initially reactive, is an important indicator of
substantially elevated intracranial pressure
and imminent transtentorial herniation.
8/9/2021

Signs/Symptoms of HI
28
General Signs and Symptoms of HI
 AMS
 Difficulty in a speaking
 Confusion
 Severe headache
 Nausea and vomiting
 Weakness, numbness, loss of sensation, paralysis
 Clear fluid from nose or ears
 Seizures, amnesia.
 Unequal pupils
 Problems with vision
 Breathing problems or irregularities
 Focal neurological deficits
8/9/2021

Signs/symptoms Cont…
Signs of basal skull fracture
The double ring sign (Halo’s Sign)
Periorbital ecchymosis (Racoon’s Eye)
Ecchymosis behind the ear in the
mastoid region (battle’s sign)
CSF Otorrhea-middle fossa
CSF Rhinorrhea-anterior fossa
8/9/2021

Signs/symptoms Cont…
Focal neurological deficits signs/lobar contusions
 Basal ganglia - Contralateral sensory loss/ hemiparesis,
homonymous hemianopia, miosis, dysphasia.
 Cerebral cortex/Lobar- Contralateral hemiparesis or
sensory
loss, homonymous hemianopia, aphasia, apraxia.
 Brain stem- Quadriparesis, facial weakness,
miosis, or autonomic instability.
 Pontine hemorrhage-Pinpoint, reactive pupils, Ataxic
respiration.
 Cerebellum- Ataxia, ipsilateral facial weakness/
sensory loss, gaze paresis, miosis, or decreased LOC.
 Uncal herniation- Fixed dilated pupil
 Frontal lobe -Anosmia.
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Diagnosis/investigation of HI
History
-Mechanism of injury.
-LOC, vomiting, drug/alcohol use, seizure.
-Anticoagulant use, headache, visual change.
Physical examination
-GCS score
- Pupil size and response, vital signs
-Motor, sensory exam, reflex & CN exam.
-Inspection & palpation of face & scalp for
lacerations/#.
-sign of basal skull #.
-Palpate spine for tenderness/deformity.
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8/9/2021

Dx/Ix Cont…
Laboratory Investigation
 CBC with HCT-base line
 BG & RH
 Coagulation profile- to exclude coagulopathy
 Renal function test-to exclude rhabdomyolysis
 Electrolyte -R/O cerebral salt wasting & DHN
 RBS
 ABG
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8/9/2021

Dx/Ix Cont…
Imaging
 X-rays: Confirm the presence and extent of a skull #.
- add very little to immediate management.
 Head CT-Scan- the main modality used in acute setting.
 MRI-Reserved for patients who have mental status
abnormality unexplained by CT-Scan & small lesions.
 Lower sensitivity for bone fractures and hyper acute blood.
EDH SDH SAH ICH
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8/9/2021

Dx/Ix Cont…
Indications for Brain CT-Scan(NICE Guide
lines)
• Witnessed LOC > 5 minutes
• Amnesia over 30 minutes
• Nausea or vomiting>2 episode
• Focal neurologic findings
• Clinical evidence of skull fracture
• Penetrating head injury
• GCS<13 on arrival/at any time, <15 after 2 hours.
• New seizure
•Age>65
•Anticoagulant use.
•Drug/Alcohol intoxication
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DDx
 Acute stroke
 Generalized tonic-clonic seizures
 Hydrocephalus
 Cerebral aneurisms
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8/9/2021

Management of HI
Goals of Management
To prevent secondary brain injury
Identify treatable mass lesions
Identify other life-threatening injuries
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MGT Cont…
General management protocol
◦ Fix ABCDEF
◦ Control ICP.
◦ Prevent secondary brain injuries.
◦ Antibiotic prophylaxis.
◦ Search & treat for associated injuries.
◦ Treat specific lesion (epidural, subdural)
◦ Long term treatment
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MGT Cont…
 Initial Approach/supportive management
◦ ATLS protocol
◦ Treat shock if present.
◦ Except for shock, restrict fluid intake to
maintenance level.
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8/9/2021

MGT Cont…
Management of ICP
 Optimal head positioning(30-45 degree)
 Osmotherapy (Mannitol vs 3% saline)
 Controlled hyperventilation-Transiently
reduces ICP by cerebral vasoconstriction.
 Barbiturate-reduce ICP that is refractory to
other conventional measures by reducing
the brain metabolic rate.
 Decompressive craniotomies- if refractory
to medications.
8/9/2021
39

Prophylactic Antibiotics
-Penetrating head injury
-Depressed/open skull fractures
-Complicated scalp lacerations
-Immunocompromised patients
-Basilar skull fracture with persistent CSF leak >7 days
oAntibiotics are NOT indicated in immediate setting for
basilar fracture.
8/9/2021
40

MGT Cont…
Management of mild brain injury (GCS-13–15)
 Primary survey
 History
 General Examination
 Neurologic Examination
 C-spine and other X-rays as indicated , head CT.
 Alcohol / drug screens as indicated
 Observe and discharge with advice
 Patient can be discharged if following criteria are
met before discharge
8/9/2021

MGT Cont…
Management of moderate brain injury(GCS 9-12)
 Initial evaluation same as for mild injury
 prevent secondary brain injury by avoiding hypoxia and
hypotension.
 CT scan after complete stabilization of patient.
 Early neurosurgery consult if intracranial hematoma seen
 Measures to reduce ICP.
 Admit and observe :- Frequent neurologic exams
 Deterioration: Manage as severe head injury
8/9/2021
42

MGT Cont…
Management of severe brain injury (GCS-3-8)
 Primary Survey and Resuscitation
 Secondary Survey
 Admit to facility – neurosurgical care
 Neurologic Re-evaluation
 Pupillary reaction
 CT scan only after hemodynamic
stabilization
 Medical therapy for raised ICP
 Immediate neurosurgeon opinion
 If needed surgical management
8/9/2021
43

MGT Cont…
 Pharmacological therapy
 Mannitol for ICP-1g/KG loading then o.4gm/kg
maintenance.
 Nimodipine is neuroprotective in subarachnoid
hemorrhage.
 Subarachnoid hemorrhage
• Bed rest & Analgesic
• Oral nimodipine 60mg q6hx21 days
• Angiography for localization of bleeding.
 Antipyretics- to Rx fever and pain relief eg:
Acetaminophen.
 Phenytoin1gm po loading then 100mg po tid for at least 7
days
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MGT Cont…
 Surgical Management Specific injuries
Surgical Decompression
• Burr-hole
• Craniotomy- bone flap is temporarily
removed from the skull to access the brain.
• Craniectomy – in which the skull flap is
not immediately replaced, allowing the
brain to swell, thus reducing intracranial
pressure
• Cranioplasty - surgical repair of a defect
or deformity of a skull.
8/9/2021
45

MGT Cont…
 Surgical Management
Indications for Surgical evacuation
• Large lobar hematoma >5cm
• Cerebellar hematoma >3cm
• The patient presents with fixed and dilated
pupils
• The intracranial pressure (ICP) exceeds 20 mm
Hg
• The GCS score decreases by 2 or more points
between the time of injury and hospital evaluation.
 No surgical intervention if collection <10ml
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8/9/2021

MGT Cont…
-Scalp injuries
-Irrigation, debridement and suture.
-Non-depressed/Linear skull #- close
observation of patient.
-Depressed skull # - hematoma evacuation, skull
elevation, & debridement within 24 hours of injury
if the depression is >8mm compared to the
adjacent skull thickness.
47
8/9/2021

MGT Cont…
SDH- with a thickness of > 1cm/ >10mm
and midline shift of > 5mm should be
evacuated regardless of GCS- Burehole.
-EDH-Emergency Craniotomy- to drain the
clot.
-SAH-Most can be managed conservatively.
- Intracerebral Hematoma – most
managed conservatively.
8/9/2021
48

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8/9/2021
Complications
 Post traumatic amnesia
 Post concussion syndrome
 Post traumatic epilepsy
 Infections:Meningitis,Osteomyelitis,
Abscess.
 Post traumatic CSF fistula and
Pneumocephalus
 Metabolic abnormalities/hyponatremia.
 Hyperpyrexia.
 Vascular abnormalities-coagulopathies,
delayed intra cerebral hematoma.
 Ischemia/Brain death.

Disposition & Nursing Management
Admission-Admit any patient with a GCS of < 9
or documented injury on CT scan to an ICU for
ICP & MAP monitoring.
 Patients with a persistent GCS < 15 should be
admitted for observation, even if the CT scan is
negative.
 Admit patients with a basilar skull fracture,
depressed or open fractures or when a linear
fracture crosses an arterial or venous groove.
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8/9/2021

Disposition & Nursing
Management
Discharge- Patients with mild head
trauma and a negative CT scan can be
discharged home with instructions for
post-head injury symptoms (headaches,
vomiting, weakness, or AMS). Generally:
1.GCS must be 15/15
2.no focal neurological deficit
3.Accompanied by responsible adult
4.verbal and written advice given.
8/9/2021
51

References
 Tintinalli’s Emergency Medicine, 9th edition.
 ATLS 2018, 10th edition.
 Up to date 21.6.
 Medscape
 Trauma, 9th edition.
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8/9/2021
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THANK YOU!!!

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