3. GENERALITIES
56-60% 0f patients with a severe head
trauma have multisystem injury, and 20%
of these patients will need surgical care.
Delay in the early assessment of head-
injured patients can have devastating
consequence in terms of survival and
patient outcome.
4. GENERALITIES
Two main mechanism are involved in the
physiopathology of every head trauma
which are the impact and impulsion
mechanisms.
The impact mechanism resulting from
direct contact will lead to bone lesions,
lacerations of the scalp, hemispheric
contusions and hemorrhage.
5. GENERALITIES
While the impulsion mechanism from an
acceleration or deceleration will lead to diffuse
axonal injury, contusion and the damage of
blood vessels of the brain.
Injury to the head can be classified as primary
brain injury or secondary brain injury.
Primary brain injury occurs at the time of
impact and includes injuries such as brainstem
and hemispheric contusions, diffuse axonal
injury and cortical lacerations.
6. GENERALITIES.
Secondary brain injury occurs at some
time after the moment of impact and is
often preventable. The principle causes of
secondary brain injury are hypoxia,
hypotension, raised ICP, reduced cerebral
perfusion pressure, pyrexia, cerebral
emboli, seizures and meningitis.
7. Head injury can be classified using the
GCS as.
mild GCS of 14-15
moderate GCS of 9-13
severe GCS of ≤ 8
NB. A cervical spine injury should be
considered to be present in any
patient with multisystem trauma.
8. GOALS OF MANAGEMENT
Our main aim of management will be to
prevent secondary brain injuries as
mentioned above.
Prevent the aggravation of already
existing injury of the vertebral column.
Prevent sub infection of open head
trauma.
To prevent long term sequelae of head
injured patients( neuropsychology,
seizure)
9. Means
Therapeutic or medical in the case of mild
and moderate trauma.
Surgical means in the case of moderate
and severe trauma.
physiotherapy
10. Initial management
This entails resuscitation and a primary survey
Support and stabilize airway, breathing, and circulation
(ABCs).
Intravenous resuscitation solutions should consist of
isotonic Ringer's lactate (LR) or normal saline (NS)
100cc/ hr. Fluids should be infused until the patient is
euvolemic.
The head of the patient is positioned to be 30 degrees
to the plain of the bed.
Make an initial assessment of the patient during the
primary survey (alert, voice, pain, unresponsive).
A history, including the mechanism of injury, past
medical history, drug intake, should be completed.
11. Initial management
Perform a mini-neurologic examination and
repeat frequently (GCS, focal neurological
deficits, pupil size and response should be
included.
Examine the skull for fractures, Battle's sign
(blood in the ear canal or ecchymosis over
mastoid process), Raccoon's eyes (periorbital
ecchymosis), or rhinorrhea. If any of these
signs are present, the patient requires
admission and a neurosurgical consultation.
12. Secondary management
A complete physical examination is done which
also include a detailed examination of the head,
face and neck.
Patients with mild head trauma, who have brief
amnesia of events, without loss of consciousness,
may be discharged on analgesics with instructions
if reliable observation is ensured.
If the Glasgow coma scale is 14 or less, or if loss
of consciousness was for more than a few seconds,
a head CT-scan should be obtained.
13. Secondary management
If the Glasgow coma scale is less than 8 or if
unequal pupils, lateralizing deficits, or open
head injury, there is a high probability of a
subdural, epidural, or intracerebral bleed or
diffuse axonal injury. This patient requires ICU
admission after obtaining a CT-scan of the
head and a neurosurgical consultation.
14. Ongoing management
Continually reassess ABCs,systolic blood pressure,
heart rate, and pulse oximeter. Serial hemoglobin or
hematocrit should be obtained.
Intubation and moderate hyperventilation, can be
done in the case of severely injured patients
producing moderate hypocapnia (PCO2 to 4.5–5 Kpa)
This will temporarily reduce both intracranial blood
volume and intracranial pressure.
Administer diuretics to reduce brain swelling
( mannitol 0.25- 0.5g/kg or Furosemide 1mg/kg)
15. Ongoing management
Open head wounds should be cleaned and
repaired.
Tetanus prophylaxis should be given with 0.5
cc tetanus toxoid IM, with.
In the presence of seizures, prophylactic
anticonvulsants should be use
( Phenobarbital 3-5mg/kg/ day)
16. Ongoing management
Stress ulcer prophylaxis with H2-blockers
(ranitidine, cimetidine) should be administered
Electrolytes and fluid balance should
maintained.
17. Conclusion
Head trauma or injury needs rapid and
effective management to prevent its
disabling sequelae.
The management of head injury can be
done in 3 folds
initial management(primary survey and
resuscitation)
secondary survey
ongoing management
