This document discusses traumatic brain injuries (TBI), including closed and open head injuries. It provides details on the causes, symptoms, treatments, and scales used to measure the severity of TBIs. The leading causes of TBIs worldwide are traffic accidents and falls. Closed head injuries account for about 75% of brain injuries and can range from mild concussions to severe injuries involving brain damage. Open head injuries involve skull fractures and have risks of infection, bleeding in the brain, and other complications if not promptly treated.

1. Head Trauma

2. Traumatic brain injury
Traumatic brain injury
is defined as damage to the brain resulting from
external mechanical force, such as rapid acceleration
or deceleration, impact, blast waves, or penetration by
a projectile. Traumatic brain injury

3. Demographics of Head
Trauma Woldwide

4. • TBI is a major cause of death and disability
worldwide, especially in children and young adults.
• Males sustain traumatic brain injuries more
frequently than do females , However, when matched
for severity of injury, women appear to fare more
poorly than men.
• TBI is present in 85% of traumatically injured
children, either alone or with other injuries.
• The greatest number of TBIs occur in people aged
15–24 Because TBI is more common in young
people, its costs to society are high due to the loss
of productive years to death and disability.
• The highest rates of death and hospitalization
due to TBI are in people over age 65.
• The incidence of fall-related TBI in First
World countries is increasing as the
population ages; thus the median age
of people with head injuries has
increased.

5. Almost 1.24 million
people worldwide die every
year as a result of a road
traffic accident and 20
million to 50 million more
people suffer non-fatal
injuries, with many incurring
a disability as a result of their
injury, the World Health
Organisation has said:
Without action, road traffic
crashes are expected to
result in the deaths of about
1.9 million people a year
worldwide by 2020.

6. • A study at Al Ain Hospital found the most
common cause of head injury was a road traffic
collision (67.1 per cent), followed by falls (11.9 per
cent) as the second-most common.
• Researchers examined data collected over three
years from the hospital’s trauma registry and
focused on patients with a head injury who had
died at the hospital or were treated there for
more than 24 hours.
• “With an estimated mortality rate of 37 per 100,000
of the population, this makes the road traffic
accident mortality rates in the UAE one of the
highest in the world,” said Dr Ashraf Hefny, a
specialist surgeon at Al Rahba Hospital in Abu
Dhabi and the co-author of the study.

7. Two types of brain injury occur
• Closed brain injury
• Open brain injury

8. Closed Head Injury
• Resulting from falls, motor vehicle
crashes,… etc.
• Focal damage and diffuse damage to axons
• Effects tend to be broad (diffuse)
• No penetration to the skull

9. Open Head Injury
• Results from bullet wounds, etc.
• Largely focal damage
• Penetration of the skull
• Effects can be just as serious

10. Closed-head injuries:
• are a type of traumatic brain injury in which the skull and
dura mater remain intact.
• Closed-head injuries are the leading cause of death in
children under 4 years old and the most common cause
of physical disability and cognitive impairment in young
people.
• account for about 75% of the estimated 17 million brain
injuries that occur annually in the United States.
• Brain injuries such as closed-head injuries may result in
lifelong physical, cognitive, or psychological impairment
and, thus, are of utmost concern with regards to public
health.

11. Causes of Closed-head injuries:
• are caused primarily by vehicular accidents, falls, acts of
violence, and sports injuries.
• Falls account for 35.2% of brain injuries in the United
States, with rates highest for children ages 0–4 years and
adults ages 75 years and older.
• Boys aged 0–4 years have the highest rates of brain
injury related hospital visits, hospitalizations, and deaths
combined.
• Multiple mild traumatic brain injuries sustained over a
short period of time (hours to weeks), often seen with
sports-related injuries, can result in major neurological
or cognitive deficits or fatality.
• Closed-head injuries can range from mild injuries to
debilitating traumatic brain injuries and can lead to
severe brain damage or death.

12. Closed-head injuries can range from mild injuries to debilitating traumatic
brain injuries and can lead to severe brain damage or death.
Common closed-head injuries include:
• Concussion – a head injury resulting in temporary dysfunction of normal brain
function. Almost half of the total concussions reported each year are sports-related
.
• Intracranial hematoma – a condition in which a blood vessel ruptures causing
a pool of blood to form around the brain (subdural hematoma) or between the
brain and the skull (epidural hematoma). Intracranial hematoma causes an
increase in pressure on the brain and requires immediate medical attention.
• Cerebral contusion – a bruise to the brain tissue as a result of trauma.
• Diffuse axonal injury – an injury to the axon of the neuron. These injuries are
frequently seen in car accidents and cause permanent damage to the brain.
Severe diffuse axonal injuries often lead to comas or vegetative states.

13. Opened head injuries :
• open head injury refers to a trauma to the head where the skull gets
punctured.
• They can occur in car crashes, sports accidents, workplace
accidents, or gunshot or knife wounds that create a skull fracture.
• If the object exits in a different location than where it entered, as in a
gunshot wound, it’s known as a perforating open head injury.
• An open head wound would create a more serious brain injury than a
closed head wound.
• Because there is an open wound, open head injury victims may suffer
from infection and contamination.

14. Causes of opened head injuries :
• The top three causes are…..
 car accident
 firearms
 falls

15. Skull Fractures
Open head injuries differ depending on the type of skull fracture, of which there
are four:
 Linear Skull Fracture :
Linear skull fracture, or a crack in the skull, accounts for about 69 percent of all
open head injuries. Because the injury does not penetrate brain tissue, most
linear skull fractures are minor and require little treatment. Nonetheless, it is
important to seek immediate medical attention after any traumatic brain injury,
including a linear skull fracture.
 Basilar Fracture and Diastatic Fracture :
Typically seen in newborns and older infants, diastatic fractures occur when
the skull's suture lines (areas where the bones fuse together during childhood)
are widened.

17. Depressed Skull Fracture :
are often the result of a severe blow to the head with a blunt object.
Unlike linear skull fractures, which only break the surface of the skull,
broken skull fragments from depressed skull fractures penetrate or
compress brain tissue and can cause severe brain damage

18. Open Head Injury Complications
Most open head injuries expose the brain to the outside environment, leaving
victims extremely susceptible to infection. If left untreated, infection can cause
permanent brain damage or death.
The most common type of infection resulting from open head injuries is
meningitis caused by bacteria or viruses, meningitis is usually treated with
aggressive antibiotics and drugs that reduce brain swelling (corticosteroids).
In addition to meningitis, open head injury can leave the brain vulnerable to other
complications, including:
 Seizures
 Dementia
 Paralysis
 Coma
 Death
All traumatic brain injury victims also risk suffering from intracranial hematoma,
or bleeding in the head or brain.

19. Symptoms
If symptoms of a head injury are seen after an accident, medical care is necessary
to diagnose and treat the injury. Without medical attention, injuries can progress
and cause further brain damage, disability, or death.
Common symptoms :
Because the brain swelling that produces these symptoms is often a slow
process, these symptoms may not surface for days to weeks after the injury.
Common symptoms of a closed-head injury include:
 Insomnia
 Memory Problems
 Poor concentration
 Depression
 Anxiety
 Irritability
 Headache
 Dizziness
 Fatigue
 Noise/light intolerance

20. Severe Injury Symptoms:
Severe head injuries can lead to permanent vegetative states or death, therefore
being able to recognize symptoms and get medical attention is very important.
Symptoms of a severe closed-head injury include:
 Coma
 Seizures
 loss of consciousness

21. Secondary Symptoms:
Secondary symptoms are symptoms that surface during rehabilitation from the
injury including social competence issues, depression, personality changes,
cognitive disabilities, anxiety, and changes in sensory perception.
More than 50% of patients who suffer from a traumatic brain injury will develop
psychiatric disturbances Although precise rates of anxiety after brain injury are
unknown.
A 30-year follow-up study of 60 patients found 8.3% of patients developed a panic
disorder, 1.7% developed an anxiety disorder, and 8.3% developed a specific
phobia.
Patients recovering from a closed-head or traumatic brain injury often suffer from
decreased self-esteem and depression. This effect is often attributed to difficulties
re-entering society and frustration with the rehabilitation process.
Patients who have suffered head injuries also show higher levels of
unemployment, which can lead to the development of secondary symptoms.

22. Glasgow Coma Scale
 The Glasgow Coma Scale is commonly used to assess the severity of
traumatic brain injuries, including closed-head injuries.
 The scale tests a patient’s eye, verbal, and motor responses.
 The scale goes up to fifteen points; with fifteen being the most mild injury,
less than eight being a severe brain injury, and three being a vegetative state.

23. Glasgow Coma Scale
1 2 3 4 5 6
Eye
Does not open
eyes
Opens eyes in
response to
painful stimuli
Opens eyes in
response to
voice
Opens eyes
spontaneously
N/A N/A
Verbal
Makes no
sounds
Incomprehensi
ble sounds
Utters
inappropriate
words
Confused,
disoriented
Oriented,
converses
normally
N/A
Motor
Makes no
movements
Extension to
painful stimuli
(decerebrate
response)
Abnormal
flexion to
painful stimuli
(decorticate
response)
Flexion /
Withdrawal to
painful stimuli
Localizes
painful stimuli
Obeys
commands

24. Generally, brain injury is classified as:
 Severe, with GCS < 9.
 Moderate, GCS 9–12 (controversial).
 Minor, GCS ≥ 13.

25. Diagnosis
 After sufficient information has been obtained regarding patient history,
appropriate physical and neurologic examinations are performed.
 The neurologic assessment begins with ascertaining the GCS score.
 Brainstem examination – Pupillary examination, ocular movement
examination, corneal reflex, gag reflex
 Motor examination
 Sensory examination
 Reflex examination
 Anatomical imaging with MRI is very sensitive and accurate in
diagnosing cerebral pathology in TBI patients. However, conventional
CT (which is more available and cost effective, requires shorter imaging
time and is easier to perform on patients who are on ventilator support,
in traction, or agitated) is the initial imaging modality of choice during
the first 24 h after the injury .

26.  CT is also superior in evaluating bones and detecting acute
subarachnoid or acute parenchymal hemorrhage.
 CT can miss small amounts of blood .
 CT findings may lag behind actual intracranial damage, so that
examinations performed within 3 h of trauma may underestimate injury.

27. Laboratory studies
 CT scans should be repeated after a normal admission .
Sodium  levels: Alterations in serum sodium levels occur in as many as 50% of
Forty-eight to 72 h after injury, MRI is generally considered to be
comatose patients with head injuries; hyponatremia may be due to the syndrome
superior to CT. Although CT is better at detecting bony pathology and
of inappropriate antidiuretic hormone (SIADH) or cerebral salt wasting; elevated
sodium certain levels types in head of early injury bleeds.
indicate simple dehydration or diabetes insipidus
 MRI is superior to CT in detecting axonal injury, small areas of
Magnesium levels: These are depleted in the acute phases of minor and severe
head injuries
contusion, and subtle neuronal damage.
Coagulation  Moreover, studies: MRI is Including better at prothrombin imaging the time brainstem, (PT), activated basal partial
ganglia, and
thromboplastin time (aPTT), and platelet count; these are important to exclude a
coagulopathy
thalami. However, although the greater sensitivity of MRI is helpful in
the subacute and chronic settings.
 In the acute stage, CT is more sensitive than MRI, as the clot signal can
Blood alcohol levels and drug screens: May help to explain subnormal levels of
consciousness and cognition in some patients with head trauma
be indistinguishable from brain parenchyma on MRI. After the first few
hours, the hemoglobin in the contusion loses its oxygen to become
deoxyhemoglobin, which is still not well visualized on T1-weighted
MRI, but the concentration of red blood cells and fibrin can cause low
signal on T2-weighted images. Over the next several days, as the
contusion liquefies and the deoxyhemoglobin oxidizes to
methemoglobin that is strongly paramagnetic, the contusion becomes
more easily visualized on MRI.
Renal function tests and creatine kinase levels: To help exclude rhabdomyolysis if
a crush injury has occurred or marked rigidity is present
Neuron-specific enolase and protein S-100 B: Elevated serum levels may correlate
with persistent cognitive impairment at 6 months in patients with severe or mild
head injuries.

28. Angiography
 Once a common diagnostic study in persons with acute head injury,
angiography is rarely used in the evaluation of acute head injury
today. However, conventional angiography has been the screening
and diagnostic modality of choice for identifying blunt
cerebrovascular injuries (BCVI) in trauma patients .

29. Head Trauma Treatment & Management
Mild head injury
 Most head injuries are mild head injuries.
 Most people presenting with mild head injuries will not have any progression
of their head injury; however, up to 3% of mild head injuries progress to more
serious injuries.
 Mild head injuries may be separated into low-risk and moderate-risk groups.
Patients with mild-to-moderate headaches, dizziness, and nausea are
considered to have low-risk injuries. Many of these patients require only
minimal observation after they are assessed carefully, and many do not require
radiographic evaluation. These patients may be discharged if a reliable
individual can monitor them.
 After a mild head injury, those displaying persistent emesis, severe headache,
anterograde amnesia, loss of consciousness, or signs of intoxication by drugs
or alcohol are considered to have a moderate-risk head injury. These patients
should be evaluated with a head CT scan. Patients with moderate-risk mild
head injuries can be discharged if their CT scan findings reveal no pathology,
their intoxication is cleared, and they have been observed for at least 8 hours.

30. Moderate and severe head injury
 The initial resuscitation of a patient with a head injury is of critical
importance to prevent hypoxia and hypotension.
 The results of the CT scan help determine the next step. If a surgical
lesion is present, arrangements are made for immediate transport to
the operating room. Fewer than 10% of patients with TBI have an initial
surgical lesion.
 If no surgical lesion is present on the CT scan image, The first phase of
treatment is to institute general measures intravenous fluids are
administered to maintain the patient in a state of euvolemia or mild
hypervolemia .
 Fluid restriction decreases intravascular volume and, therefore,
decreases cardiac output. A decrease in cardiac output often results in
decreased cerebral flow, which results in decreased brain perfusion
and may cause an increase in cerebral edema and ICP. Thus, fluid
restriction is contraindicated in patients with TBI.

31.  Another supportive measure used to treat patients with head injuries is
elevation of the head.
 When the head of the bed is elevated to 20-30°, the venous outflow from the
brain is improved, thus helping to reduce ICP. If a patient is hypovolemic,
elevation of the head may cause a drop in cardiac output and CBF; therefore,
the head of the bed is not elevated in hypovolemic patients.
 Sedation
 The use of anticonvulsants in patients with TBI is a controversial issue. No
evidence exists that the use of anticonvulsants decreases the incidence of late-onset
seizures in patients with either closed head injury or TBI. Therefore, the
prophylactic use of anticonvulsants is not recommended for more than 7 days
following TBI and is considered optional in the first week following TBI.
 ICP monitoring is indicated for any patient with a GCS score less than 9, any
patient with a head injury who requires prolonged deep sedation or
pharmacologic relaxants for a systemic condition, or any patient with an acute
head injury who is undergoing extended general anesthesia for a
nonneurosurgical procedure.
 . ICP may be monitored by means of an intraparenchymal monitor, an
intraventricular monitor (ventriculostomy), or an epidural monitor.

32.  In adults, the reference range of ICP is 0-15 mm Hg.
 Maintaining ICP within the reference range is part of an approach
designed to optimize both CBF and the metabolic state of the brain.
 Diuretics are powerful in their ability to decrease brain volume and,
therefore, to decrease ICP. Mannitol, an osmotic diuretic, is the most
common diuretic used.
 Surgery:
 Removing clotted blood (hematomas).
 Repairing skull fractures.
 Opening a window in the skull.
 Rehabilitation
Patients may need to relearn basic skills, such as walking or talking.
The goal is to improve their abilities to perform daily activities.

33. Prevention
 Always wear a seat belt in a motor vehicle. Small children should
always sit in the back seat of a car and be secured in child safety seats
or booster seats that are appropriate for their size and weight.
 Don't drive under the influence of drugs, including prescription
medications that can impair the ability to drive.
 Wear a helmet while riding a bicycle, skateboard, motorcycle..etc
 Remove hazards in the home that may contribute falling.

34. Thank you
Dr Sahar Sasi