This document defines traumatic brain injury and describes the etiology, pathophysiology, classification, and management of head injuries. The most common causes of head injury are motor vehicle accidents, falls, assaults, and firearms. Injuries are classified as impact injuries resulting from an object striking the head or acceleration/deceleration injuries from differential movement within the skull. Primary injuries occur at impact and secondary injuries involve progressive brain damage. Complications can include increased intracranial pressure, brain swelling, infections, and long-term effects such as personality changes and dementia. Management involves stabilizing the patient, treating raised ICP, monitoring for complications, and long-term rehabilitation.

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
R
BManualOfSurgery
Death&
DeductionForensicMedicine
A
ManualOnClinicalSurgery