This document provides guidance on the evaluation and management of head injuries. It discusses examining the scalp, eyes, ears and skull for fractures. It recommends CT scans for significant closed or penetrating head injuries to identify hemorrhages, contusions or fractures. It provides criteria for operative intervention in head injuries based on factors like intracranial pressure, Glasgow Coma Scale score and size of hematomas. It also outlines general management principles like maintaining blood pressure, oxygen levels and ICP. The document provides a thorough overview of evaluating and treating various types and severities of head injuries.

2.  Scalp: Laceration, depressed fracture or open
fracture
 Eye: Pupillary size, reactivity, visual acuity,
hemorrhage, eye ball movements (restricted
in orbital fracture)
Eyes to be examined first later swelling may
obscure examination.
 Tympanum: Hemotympanum and otorrhea

3. Basilar skull fracture is a fracture of the base of
the skull, typically involving the temporal,
temporal, occipital, sphenoid and ethmoid
bone.
1. Otorrhea
2. Rhinorrhea
3. Raccon eyes
4. Battle’s sign (Ecchymosis behing ear)

5. All patients with significant closed head injury
or penetrating head injury must undergo CT
scan of head.
If patient of penetrating head injury is unstable
at least a plain X ray of head my be helpful.
Hematomas, contusions, ventricular
hemorrhage, sub arachnoid hemorrhage and
diffuse axonal injury.

9. Hemorrhage in space between arachnoid and
pia mater. Cause vasospasm and decreased
cerebral flow.

10. High speed deceleration injury causing
sheering stress to brain . Represent direct
axonal damage
CT may demonstrate blurring of grey and white
matter interface and multiple small punctuate
hemorrhage but
MRI is investigation of choice.

13.  Carotid or vertebral artery injury may lead to
stroke syndrome.
 If suspected 4 vessel angiography for carotid
and vertebral arteries.

14. Access Glasgow coma scale:
If GCS less than 14 in closed head injury perform CT head
If intracerebral bleed or diffuse axonal injury admit to SICU

15.  If GCS less than 8 or abnormal CT finding
monitor intra cranial pressure using intra
parenchymal or intra ventricular catheter.
 Unless ICP is more then 20 mmHg operative
therapy is not initiated.
 Operative decesion for SOL depends upon:
A. Size of clot
B. Midline shift (>5mm)
C. Clot location (Posterior fossa )
D. GCS score
E. ICP
 Those having diffuse cerebral edema will require
decompressive craniotomy.
 Open or depressed fracture and penetrative head
injuries are indication for operative intervention.

16.  Keep systolic BP above 90mm Hg
 Prevent hypoxia by keeping oxygen saturation
above 90%
 Keep cerebral perfusion pressure 50- 70mm Hg.
 Patient may be hyper ventilated to make pCO2
<30 mm Hg to induce cerebral vasoconstriction
for temporary management of raised ICP
 Moderate hypothermia (32 to 33 Celsius)
maintained for at least 48 hours reduce overall
mortality.
 Patients with intracranial hemorrhage must be
given prophylactic anticonvulsant therapy.
 Sedation, osmotic diuresis, paralysis, ventricular
drainage and barbiturate coma are used in
sequence as last resort.

17.  Grasp upper palate and see if it moves apart from rest of head.
 Conscious patient ask if he feel his bite normal.
 Le forte’s classification:
 type 1
◦ horizontal maxillary fracture, separating the teeth from the upper face.
◦ fracture line passes through the alveolar ridge, lateral nose and inferior
wall of maxillary sinus.
 type 2
◦ pyramidal fracture, with the teeth at the pyramid base, and nasofrontal
suture at its apex
◦ fracture arch passes through posterior alveolar ridge, lateral walls of
maxillary sinuses, inferior orbital rim and nasal bones.
 type 3
◦ craniofacial disjunction
◦ fracture line passes through nasofrontal suture, maxillo-frontal suture,
orbital wall and zygomatic arch.

19. 1. Vigorous nasal
2. Air way compromise – blood in posterior
pharynx
3. Vomiting due to swallowed blood
Nasal packing or balloon tamponade.

20.  Control ongoing hemorrhage with nasal
packing, foley’s balloon tamponade and oro-
pharangeal packing .
 Involve trauma surgeon, ENT surgeon,
ophthalmologist, maxillofacial surgeon.
 Early involvement of concerned surgeons is
obviated as permanent disfigurement or loss
of any senorineural function in this region
gives a very bad psychological impact after
recovery.

21.  Unless proved otherwise in head trauma
cervical spine injury is present.
 An occult cervical spine trauma may result
quadriplegia
 Penetrating injuries of neck that violates
platysma are life threatening as density or
critical structures.
 Other injuries could be fracture of larynx
must be suspected if patient has hoarseness
in voice, subcutaneous emphysema and
palpable fracture.

24.  Best is CT neck
 If not feasible 5 X rays
1. Lateral view visualizing C7 through T1.
2. Antero posterior view
3. Trans oral odontoid view
4. Bilaterally oblique view
Occult spinal trauma suspected in patient having
delayed neck pain. Radiographed in flexion and
extension view only by an experienced neck
surgeon.

26.  Injury to vessels may require repair. Extensive injury to unilateral
jugular vein my be manged by ligation instead but never bilateral
cases.
 In blunt injury to carotids and vertebral arteries administration of
antithrombotic have shown to decrease incidence of strokes
following neck trauma. Repeat scan after 10 days if not healed
continue treatment for 6 months
 Sublaxations are stabilized using axial traction with cervical
tongs and immobilized with spinal orthoses (braces).
 If cord injury present give stat bolus dose of methylprednisolone
30mg/kg followed by 5.4mg/kg/hr perfusion for rest of 23 hrs.
 In deteriorating neurological functions and fracture or
dislocation with incomplete neurological deficit immediate
surgery is warranted.

28. 1. Expanding hematoma
2. Airway compromise
3. Dysphagia
4. Subcutaneous emphysema
5. hoarsness

29.  Blunt
Physical examination
Chest X ray
CT
Repeat chest X ray if intubation, central line,
tube thoracostomy to check adequacy of
procedure.

30.  Must be suspected as soon as widening of
mediastinum is seen.
 7% have normal chest X ray thus screening
with spiral CT performed in following
patients:
1. High energy decelration motor vehicle
collision with frontal or lateral impact.
2. Motor vehicle collision with impact.
3. Fall > 25feet.
4. Direct impact (horse kick to chest)

31. More than 95% of patients with aortic tear who
survive till reaching to emergency department
have tear just distal to subclavian artey where
it is tethered by ligamentum atreriosum.
Rest 2-5% are in ascending, transeverse arch or
diaphragm.

33.  1. Intimal tear
 2. Intra mural hematoma
 3. Pseudo aneurysm
 4. Rupture

35. X ray finding of aortic tear
Widened mediastinum
Abnormal aortic contour
Tracheal shift
Nasogastric tube shift
Left apical cap
Left or right paraspinal stripe thickening
Depression of the left main bronchus
Obliteration of the aortico pulmonary window
Left pulmonary hilar hematoma

37.  Investigate with:
1. Chest X ray with metallic marking of entry and
exit wound
2. Pericardial USG
3. Central venous pressure monitoring
These will identify most of injuries except injury to
trachea and esophagus
Thus,
if persistant air leak from chest tube or air in
mediastinum--- bronchoscpy
If esophageal injury suspected esophagography
followed by barium study to look for
extravasation .

38.  Simple lacerations of ascending or transverse
aorta is done with lateral aortorraphy.
 Repair of posterior injuries or using
interpositoning graft will require circulatory
arrest.
 Innominate artery injuries are repaired using
bypass exclusion technique where circulatory
arrest is not required. Here before entering the
post injury hematoma PTFE graft is attached end
to side to proximal part of aorta and end to end
innominate artery.
 Descending aortic rupture will require urgent
repair.
 Subclavian artery lateral arteriorraphy or PTFE
interposition is done sine due to multiple braches
and tethering end to end anastomosis is not
preferable.

39.  In impending rupture to prevent Esmolol
infusion could be given with target systolic BP
<100mmHg and heart rate <100/min.
 Endovascular stenting techniques are gaining
hold nowadays especially in those who can’t
tolerate single lung ventilation during open
repair.
 While repair a centrifugal pump maintaining
perfusion pressure more than 65mm Hg
prevent ischemia to spinal cord and before
tying last suture thrombus and air is flushed
out.

40.  Before going for any repair control
hemorrhage.
 Atrial rupture can be clamped with satinsky
clamp. For ventricular rupture either digital
pressure or skin staplers are used.
 For definite repair 3-0 prolene is used either
continuous or interrupted manner.
 Continuous is avoided near coronaries,
instead horizontal mattress is preferred.
 Pledgeted sutures are used for thinner
myocardium of right ventricle.

41. Rare injuries and rarely require operative
management. First secure air way for ventilation.
Tracheal injuries require debridement of
devitalized tissues and repair with 3-0 PDS
suture. Sutured area is covered with some
vascular structure like pericardium, pleura and
intercoastal muscle.
Bronchial injury less than 1/3rd circumferential
injury can be conservatively managed and if
persistent air leak in chest tube bronchoscopic
fibrin glue can be used.

42.  For parenchymal injury traditionally
pneumonectomy or lobectomy was done but
now pulmonary tractotomy is done thus
selective bronchioles and bleeders could be
ligated.
 Pneumatocele can be managed conservatively
but if abscess develop CT guided drainage is
to be done.
 For esophageal injury single layer repair is
enough but if nearby some tracheal suture
line is present some vascularised tissue must
be interposed. If lower esophageal injury
present segmental resection and gastic pull
up can be done.

43. In a case of abdominal trauma per abdomen
rigidity or hemodynamic instability is an
indication for promt surgical exploration.
 Penetrating
 Blunt

44. Gun shot injuries
>90% of gun shot injuries cause serious internal damage.
Thus any gun shot wound having entry or exit wound
between 4th intercoastal space to pubic symphysis and its
trajectory penetrating the peritoneum needs abdominal
exploration.
There is an expection: When gun shot wound is in upper
right quadrant and trajectory is confined to liver we can
manage it conservatively if other things are favourable.
If location of wound is in back or flanks then exploration is
more difficult as organs are located retro peritoneally

45. Stab Wound
 Less organ damage than gun shot wound.
 Wounds must be examined in emergency
department itself under local anesthesia.D
 If superficial to fascia patient can be
discharged.
 If fascia penetrated then further evaluation
required:
1. Serial examinations
2. Diagnostic peritoneal lavage
3. CT scanning with triple contrast

46.  Surgical diagnostic test to determine
hemorrhage in abdominal cavity.
 Through infraumbilical incision peritoneum is
entered and aspirated using a stiff catheter. If
less than 10 ml 1 liter 0.9% warm normal
saline is infused and aspirated for analysis.
 Analysis results are different for
thoracoabdominal stab wonds and standard
anterior abdominal.

48. Anterior abdominal
stab wounds
Thoracoabdominal
stab wounds
Red Blood cell counts >1,00,000/ml >10,000/ml
White blood cell
counts
>500/ml >500/ml
Amylase level >19 IU/ml >19 IU/ml
Alkaline phosphatase
level
>2 IU/ml >2 IU/ml
Bilirubin level >0.01 mg/dL >0.01 mg/dL

50. Initial evaluation by FAST(focused abdominal
sonography in trauma). Since its not 100%
sensitive DPL is still advocated in
hemodynamically unstable patients.
In hemodynamically stable CT scan must be
done if FAST is negative.
CT has limited sensitivity for intestinal injury
suggestive findings thickened bowel wall,
streaking of mesentery, free fluid without any
solid organ injury or free intraperitoneal gas.

53. Grade Sub capsular
hematoma
Laceration
I < 10% of surface area <1 cm in depth
II 10-50% of surface
area
1-3 cm in depth
III >50% of surface area
or >10 cm in depth
>3cm
IV 25-75% of hepatic
lobe
V >75% of hepatic lobe
VI Hepatic avulsion

54. Grade Subcapsular hematoma Laceration
I <10% of surface area <1cm in depth
II 10-50% of surface area 1-3 cm
III >50% of surface area or
>10 cm in depth
>3cm
IV >25%devascularisation Hilum
V Shattered spleen
Complete
devascularisation

55.  Liver
Being large organ it is most suseptible to injury.
Can be manged conservatively if patient
hemodyanmically stable and there is no
peritonitis or any other indication for laparotomy.
Anigio embolization and ERCP further improves
outcome of conservative management.
Perihepatic packing must be done for injuries to
liver and lacerated edges must be opposed to
control bleeding by local pressure.
In case of persistent bleeding despite packing
injury to hepatic and portal vessel must be
considered.

56. Pringle’s manuever must be used to find site of bleed.
Ligation of celiac axis at the level of common hepatic
upto gastroduodenal branch is well tolerated due to
many collaterals but if hepatic artery prper is
damaged definitive repair is warranted.
Sometimes in emergency any of hepatic artery or even
portal vein will have to be ligated but then delayed
anatomic resection for lobar necrosis will have to be
done. If right sided hepatic artery is ligated
cholecystectomy has to be done.

57.  Earlier splenectomy was warranted in all splenic
injuries but after recognition of immune function of
spleen splenic salvage is advocated.
 Proper patient selection is important. 20-30% of
splenic trauma deserve splenectomy.
 Indications for splenectomy in trauma
1. Those requiring blood transfusion in 1st 12 hours.
2. Hilar injuries
3. Pulverized splenic parenchyma
4. Injury more than grade two in a patient having
coagulopathy or multiple injuries.
Polar injuries can be managed with patial splenectomy.
Horizontal matress over raw edges can control bleeding.

58.  Injuries to stomach are liable to be missed
thus by occluding stomach at pylorus inject
methylene blue using nasogastric tube.
 If require partial gastrectomy can be done
followed by billroth reconstruction.
 If Latarjet nerve or vagi has been injured then
a drainage procedure is warranted.
 If single layer closure is done full thickness
bite is required to prevent hemrrhage.

59.  Hematomas can be managed non operatively
just by nasogastric suctioning and parentral
nutrition.
 Simple tear and laceration can be managed by
single layer suture

60.  May produce complex fractures with major
hemorrhage
 Radiograph shows only gross injuries thus CT
required in majority of cases.
 Bladder rupture may occur if direct blunt
injury to torso in full bladder
 If urine positive for RBC CT cystography
indicated.

61. 1. Blood at meatus
2. Scrotal and perineal hematoma
3. High riding prostate on PR examination
Perform urethrogram before doing foley
catheterization to avoid false passage and
stricture.