9. SEVERITY
Minimal: GCS 15,
no LOC or
amnesia
Mild: GCS 13 -15 +
LOC or amnesia
impaired alertness
or memory
Moderate: 9-12 or
LOC ≥ 5 min or
focal neurological
deficit
Severe: GCS 3 - 8
10. PATHOLOGY FEATURES
• Focal
- Symptoms related to the functions
of specific damaged area
• Diffuse
- Widespread injury
22. BRAIN INJURY
SECONDARY
• Continuation of damage to the brain as a result of
physiological effects of primary injury
Hypoxemia
Hypotension
Anemia
Increase ICP
Impaired autoregulation
Hypo/hypercapnia
Hypo/hyperglycaemia
Biochemical changes
Metabolic demand
23. PRE-HOSPITAL
MANAGEMENT
• Stabilize patient at trauma scene
• Do not move patient unnecessarily
• Maintain ABC
• Protect cervical spine
• Stop active bleeding
• Relay information to receiving doctors
– ABC status
– GCS & pupil size
– Suspected injuries
• Transfer patient
24. APPROACH IN A&E
Initial assessment in the (ED)
O All patients presenting to an ED with a head injury should be
assessed within 15 minutes of arrival at hospital
25. CLINICAL APPROACH
• Mechanism of injury
• Loss of consciousness or amnesia
• Level of consciousness at scene and on
transfer
• Current symptoms / Evidence of seizures
• Probable hypoxia or hypotension
• Pre-existing medical conditions
• Medications (especially anticoagulants) /
Allergies
31. Secondary survey
• Status and protection of airway.
• General assessment and other injuries like
fractures, abdominal organ injuries, thoracic
injuries are looked for.
• Presence of any scalp haematoma, fractures of
skull bone which may be depressed has to be
looked for.
• Any blood from nose or ear, CSF rhinorrhoea or
CSF otorrhoea has to be looked for.
35. CRITERIA FOR ADMISSION
• Any altered level of consciousness
• Skull fracture
• Focal neurological features
• Persistent headache, vomiting,
systolic hypertension, bradycardia
• No CT scan available or abnormal CT
Head
• Alcohol intoxication
• Bleeding from ear or nose
• Associated injuries
• All penetrating brain injuries
36. Head injury management in A&E room
• General aims
– Stabilization
– Prevention of secondary brain injury
38. DETECTION & MONITOR
• Symptoms & sign of herniation
- High BP, irregular/slow pulse, severe headache,
weakness, cardiac arrest, LOC/coma, loss of brainstem
reflexes (blinking/gag/pupil reflex), respiratory arrest,
wide dilated pupils & no movements in one or both
eyes)
• GCS
• Pupillary Reflex
• ICP Monitor
Intracranial pressure
pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue
Normal value :7-15mmHG
Monro-Kellie Hypothesis
that the sum of volumes of brain, cerebrospinal fluid (CSF) and intracerebral blood is constant. An increase in one should cause a reciprocal decrease in either one or both of the remaining two.
The average intracranial volume in the adult is around 1700 mL, composed of brain tissue (~1400 mL), CSF (~150 mL), and blood (~150 mL)
Cerebral Blood Flow
is the blood supply to the brain in a given period of time. In an adult, CBF is typically 750 millilitres per minute or 15% of the cardiac output. This equates to an average perfusion of 50 to 54 millilitres of blood per 100 grams of brain tissue per minute. CBF is tightly regulated to meet the brain's metabolic demands. Too much blood (a clinical condition of a normal homeostatic response of hyperemia) can raise intracranial pressure (ICP), which can compress and damage delicate brain tissue. Too little blood flow (ischemia) results if blood flow to the brain is below 18 to 20 ml per 100 g per minute
Btw the skull and the outer endosteal layer of dura matter
Common vessel : middle meningeal artery (temperoparietal locus )
Frontal locus: ant ethmoidal artery
Occipital locus : transverse or sigmoid sinuses
Vertex locus : superior Sagittal sinus
Bioconvex shape
Lucid interval follow by LOC
Btw dura and arachnoid
Bridging veins
Gradually increase in headache and confusion
Cresent shaped
Blood in circle of wills ,cisterns and fissure
Rup of berry aneurysm
• Cerebral protection-physiological and pharmacolo gical interventions that precede cerebral insult. • Cerebral resuscitation-similar interventions after the insult has occurred and is a process of damage limitation
Non pharmacological treatment
Hypothermia
Avoidance of hyperglycemia
• Prevevtion and treatment of Hypotention Hypoxia Hypercapnia
• Hemodilution
• Normalisation of increased ICP
• Correction of acidosis and electrolyte imbalance
osmotherapies — mannitol 0.25-1g/kg Q3hrly — hypertonic saline (3%) 3 mL/kg over 10 min or 10-20 mL 20% saline
