head injuries - types, causes, management

1. Head Injuries

2. Definition - Traumatic brain injury (TBI)
 Trauma to the scalp, skull or brain.
 encompasses a broad range of pathologic
injuries to the brain
 Head injury = traumatic brain injury

3. Etiology
 MotorV
ehicleaccident-44%
 Falls-26%
 Other/Unknown-13%
 Non-FirearmAssaults-9%
 Firearms-8%

4. Pathophysiology/ classification of TBI
Impact injuries: It results from an object
striking the head or the head striking an
object.
It includes:
Scalp injuries - scalp contusion, abrasion and/or
lacerations, excessive bleeding,
osteomyletis.

5. Skull fracture – linear.
- depressed blunt trauma,
hemorrhage , ICP, compressed delicate tissues,
contamination and infection, cortical damage and
epilepsy.

7. Base of skull fracture
Anterior cranial fossa fracture:
subconjunctival haematoma, epistaxis, CSF rhinorrhea
Middle cranial fossa fracture:
CSF otorrhoea, haemotympanium, ossicular disruption,
Battle sign, 7th and 8th cranial nerve palsy.

8. Cerebral contusion and laceration
Epidural hematoma

9. Acceleration and deceleration injuries:
 result of differential movement between skull and
cranial content.
 It includes:
Diffuse axonal injury
Sub-dural hematoma

10. Coupinjury
Contracoupinjury
Coupinjury:
 It occurs at the site of the impact to the head .
 compression of brain due to inward movement of the
bone
Contre-coup:
Injury occurs directly opposite to
the point of impact
common in frontal and temporal
6
lobe.
Produced by the head in motion
impacting on a stationary object

11. Brain injury
Primary brain injury:
Injury caused at the time of impact
Irreversible Secondary brain injury
progressive brain damage

12. Primarybraininjury Secondarybraininjury
Concussion Intracranialhaematoma
Corticallaceration/contusion Cerebraloedema
Diffuseaxonalinjury Ischaemia
Bonefragmentation Infection
Metabolic or endocrine
disturbances

13. Diffuse Axonal Injury
 Results from mechanical shearing at grey- white
interface due to severe acceleration and
deceleration force
 No obvious structural damage
 Severity - mild damage with confusion to coma and
even death
 Major cause of unconsciousness and persistent
vegetative state after head trauma

15. Cerebral Concussion
 It is the condition of temporary dysfunction
of brain without any structural damage
following head injury
 It is manifested as:
Transient loss of consciousness
Transient loss of memory
Autonomic dysfunction like bradycardia,
hypotension and sweating

16. Cerebral Contusion
 It is more severe degree of brain injury
manifested by areas of hemorrhage in the
brain parenchyma but without surface
laceration
 Neurological deficit which persists more than
24 hour
 Associated cerebral edema and defects in the
blood brain barrier

17. Cerebral laceration
 Severe degree of brain injury associated with a
breach in the surface parenchyma
 Tearing of brain surface may be due to skull
fracture or due to shearing forces
 Focal neurological defecit may be present

18. Extradural haematoma
 Collection of blood between the cranial bones
and duramater
 It is associated with the fracture of temporo-
parietal region
 Commonest vessel: Middle meningeal artery
 Confusion, irritability, drowsiness, hemiparesis
to the same side of injury
 Features of raised ICP: hypertension,
bradycardia, vomiting

19.  CT scan: Biconvex
lesion
 It is the surgical
emergency
 Craniotomy and
evacuation of clot
is done.

20. Sub Dural Haematoma
 Collection of blood
between brain and
duramater
 Common intracranial
mass lesion resulting
from trauma
Acute: <3 days
Sub-acute: 4-21 days
Chronic: >21 days

21. Sub Dural Haemotama
 Loss of consciousness occurs immediately
after trauma and is progressive
 Features of raised ICP and focal neurological
defecits
 CT Scan: Concavo-convex lesion
 T/t: surgical decompression by craniotomy
 Antibiotics

22. Cerebral Herniation
 Increased ICP or presence of
intracranial mass may
predispose to cerebral
herniation.
 Herniation of contents of
supratentorial compartment
through the tentorial hiatus
 Herniation of the contents of
the infraintentorial
compartment through the
foramen magnum

23. Brain swelling
It follows significant
head injury
Occurs due to active
hyperaemia and
edema
Infection, Seizure, Hydrocephalus

24. Approach to Head Trauma
 Detailed history should be sought in all cases
of head trauma.
 If the patient is unconscious which is usually
the condition, history should be obtained
from the attendant.
 While one care provider is taking history,
resuscitation should be carried out
simultaneously by other care provider.

25. Ask about:
 Type of accident: ?RTA, ?fall from height
?acceleration/deceleration injury during driving
a motor car
 Level of consciousness: ?Unconscious,
?semiconscious
 If unconscious: duration of unconsciousness,
?immediately after trauma ?lucid interval
 Post traumatic amnesia

26. Ask about:
 Vomiting: ?blood in vomitus ?persistent
vomiting ?sign of recovery from cerebral
concussion
 Epileptic fits or seizure: Its nature may give
clue to localization of the site of trauma
 Swelling and pain in the head
 Other complaints: ?bleeding or watery
discharge from ear, nose and mouth

27. Ask about:
 Past history: ?fits or similar head injury in
the past
?Hypertension ?DM ?Renal diseases
 Personal history: ?unconsciousness due to
other cause (alcohol, opium poisoning,
diabetic coma)
 Family history: History of diabetes, HTN,
epilepsy in the family

28. Immediate management
 Initial assessment of head injuries must
follow advanced trauma and life support.
(ALTS)
 It includes:
Maintenance of airway along with cervical
spine control
Cervical spine immobilized in neutral
position using neck brace, sand bags,
forehead tape
Suction of airway to clear blood, vomitus
Chin lift, jaw thrust

29.  Maintenance of breathing
 Assessment of circulation and control of
haemorrhage
Establish iv access with two large bore
iv cannulas
IV infusion of NS (Avoid 5% Dextrose
as it may precipitate cerebral edema)
 Assessment of dysfunction of CNS
 Exposure in a controlled environment
Remove all clothes and look for any

30. Physical examination
 Pulse and blood pressure:
Pulse will be rapid, thready with low BP in
case of cerebral concussion
Pulse becomes slow and bounding with high
BP in case of cerebral irritation
Rapid pulse in deeply unconscious heralds
impeding death

31.  Temperature:
In cerebral concussion, contusion
temperature may remain subnormal
With appearance of cerebral compression,
temperature may rise upto 100˚F
Victor Horsley’s sign

32. Physical examination
 Head:
Patient’s head must be shaved fully
Look thoroughly for any fracture of the skull,
hematoma and assess the type of fracture
Site of injury often gives clue towards the
diagnosis.
 Position of the patient
 Eyes:
Is there any evidence of haemorrhage in and
around the eyes?
The condition of pupil

33. Neurological assessment
NeurologicalassessmentcanbedonebyusingGlasgowcomascale.

34.  Minor head injury: GCS 15 with no loss
of consciousness (LOC)
 Mild head injury: GCS 14 or 15 with
LOC
 Moderate head injury: GCS 9–13
 Severe head injury: GCS 3–8.

35.  Presence of neurological deficits:
Check for power, tone, superficial and deep
tendon reflexes
 Rigidity of the neck:
May be present in the case of subarachnoid
hemorrhage, fracture dislocation of cervical
spine
 Cranial nerve examination
Cranial nerve should be examined one after
another Of these most important is the third

36. General Examination
Examine
Chest for the fracture of the ribs, surgical
emphysema
Spine, pelvis and limbs for the presence of
fracture
Exclude abdomen for rupture of any hollow
viscus, internal haemorrhage form injury to
any solid viscus eg: liver, spleen

37. Management:
 Place a Nasogastric tube to decompress the
stomach and reduce the risk of vomiting as
aspiration
 Avoid NG tube for the patients with facial
injuries as the tube could enter the brain
through bony fracture
 Insert an dwelling urinary catheter for
hourly urine output monitoring
 Avoid insertion if urethral injury suspected

38. Treatment of raised ICP
 IV Mannitol
 IV furosemide
 Reverse Trendelenburg if no
counter indications like
hypovolaemia, spine injury
 If significant agitation and if
hypoxia, hypovolaemia or pain
is excluded as the cause of
agitation: give IV Midazolam
 Analgesics for the pain
management

39. Monitor
 Blood pressure
 Heart rate
 Respiratory rate
 Spo2
 ECG
 Blood samples for serum electrolyte
Arterial blood gas hyper/
hypoglycaemia

40. Special investigations!!!!
Definitive treatment!!!!

41. Complications
 Personality
Changes
 Hypopituitarism
e.g. DI
 Post-Traumatic
Seizures
 Infections e.g.
Meningitis
 Vasospasm,
Long-Termeffects
 Parkinson’s
 Alzheimer’sDementia

42. Rehabilitation
Physiotherapy
OccupationalTherapy
SpeechandLanguageTherapy
Psychologists/Psychiatrists

43. References
SHOR
TPRACTICEofS
U
R
G
E
R
Y
Bailey&
Love’
s25thEdition
S
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BManualOfSurgery
Death&
DeductionForensicMedicine
A
ManualOnClinicalSurgery