Approach To Head Injuries

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Slide 1: 

Approach To Head Injuries (Brain Trauma) Patients Dr. SANDEEP KANSAL M.S, DNB(SURGERY) Associate professor Dept. of Surgery Govt. Medical College, Surat

The silent epidemic : 

The silent epidemic Head Injury … The silent epidemic It occurs every 15 seconds throughout the world It is the commonest cause of morbidity and mortality world wide two thirds of victims are under 35 years of age Males are twice as affected as compared to females

The silent epidemic : 

The silent epidemic Each year one million people are treated in casualty for head injury, out of which 50,000 die and 80,000 become permanently disabled About 500 billion dollars spent each year in their management worldwide Increasing road accidents in India are attributed to unique combination of high and low speed traffic .

Definitions : 

Definitions Traumatic brain injury is an assault to the brain caused by an external physical force Acquired brain injury is an insult to the brain that has occurred after birth,e.g.TBI,stroke,near suffocation, infections in the brain, anoxia

Modes of injuries : 

Modes of injuries

Modes of Injury : 

Modes of Injury various modes viz. vehicular accidents, homicidal, industrial, domestic, armed Vehicular accidents are overwhelmingly higher than any other mode throughout the world Vehicular accidents comprise motor vehicle, bike, and Airplane crash and even sinking of boats

‘Loss of consciousness is not mandatory to label as Head Injury’ : 

‘Loss of consciousness is not mandatory to label as Head Injury’ “No head injury is so trivial as to be ignored nor so severe as to be despaired of” Hippocrates, Father of Medicine (460-377BC)

Types of Head injuries : 

Types of Head injuries Primary Secondary Closed open

-- Immediate & direct result of the trauma -- Occurs within seconds after impact, can be of variable intensity . -- May be anatomically classified as either Focal or Diffuse. -- Focal injuries : contusions, fractures, coup & contrecoup,EDH,SDH,ICH -- Diffuse injuries: concussion & diffuse axonal injury (DAI) Primary

Mechanism of injuries : 

Mechanism of injuries

Secondary : 

Secondary -- Cellular damage set into motion by the cascade of events following initial injury, that develops over hours to days after initial traumatic insult. -- It includes cerebral edema, brain herniations.



Closed head injuries : 

Closed head injuries Dura remain intact Communication between intracranial and extra cranial environment is separated

Open head injuries : 

Open head injuries Breech in continuity of dura Direct connection between intracranial and extra cranial environment


CLASSIFICATIONS OF HEAD INJURY Mechanism Severity Morphology

Mechanism : 

Mechanism Blunt --· High velocity (automobile collision) -- Low velocity (fall, assault) . Penetrating - · Gunshot wounds - · Other penetrating injuries

Penetrating : 


Signs and Symptoms Headache Dizziness Nausea / Vomiting Amnesia Decreased responsiveness Confusion Combativeness Loss of responsiveness

Assessment : 

Assessment First impression: Responsive or Unresponsive Urgent Survey: LOR ABC’s Open airway with C-spine Check breathing: Ventilate; Oral airway; O2 when available Check carotid artery pulse – CPR if indicated Control any major bleeding

Assessment continued : 

Assessment continued Rapid Body Survey Sample, DCAP-BTLS Stabilize head between knees Call for equipment, assistance, transport Maintain body temp. Transport (head uphill) Non-Urgent Survey Ongoing Survey – seizures, vomiting, change in LOR

Slide 21: 

Brain Swelling  Increased Intracranial Pressure (ICP)  Hypoxia  Further Secondary Brain Injury  More Swelling  Increased ICP

Slide 22: 

Localised Neurological Signs (ICP) GENERAL SIGNS + PLUS + Change in pupil size / light reactivity Slowing pulse Rising BP. Change in respiration Unilateral weakness Incontinence Seizure

Severity : 

Severity · Mild · GCS Score 14-15 · Moderate · GCS Score 9-13 · Severe · GCS Score 3-8 .


GLASGOW COMA SCALE (GCS) Assessment Area Score Eye Opening (E) Spontaneous 4 To speech 3 To pain 2 None 1 BEST Motor Response (M) Obeys commands 6 Localizes pain 5 Normal flexion (withdrawal) 4 Abnormal flexion (decorticate) 3 Extension (decerebrate) 2 None (flaccid) 1 Verbal Response (V) Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1

Paediatric GCS : 

Paediatric GCS Eye opening and Motor response are essentially the same Verbal response is:

Morphology. : 

Morphology. Skull Vault -- linear vs stellate Fractures --Depressed/nondepressed -- open/closed Basilar – With/without CSF leak -- With/without Vllth nerve palsy Intracranial · Focal , -- Epidural Lesions -- Subdural -- Intracerebral · Diffuse -- Mild concussion -- Classic concussion -- Diffuse axonal injury

· Skull Fractures --- · Vault : 

· Skull Fractures --- · Vault

· Skull Fractures – Vault - Depressed- 3D CT : 

· Skull Fractures – Vault - Depressed- 3D CT

· Skull Fractures – Vault - Depressed : 

· Skull Fractures – Vault - Depressed

· Skull Fractures -- · Basilar : 

· Skull Fractures -- · Basilar

Morphology. : 

Morphology. Skull Vault -- linear vs. stellate Fractures --Depressed/nondepressed -- open/closed Basilar – With/without CSF leak -- With/without Vllth nerve palsy Intracranial · Focal , -- Epidural Lesions -- Subdural -- Intracerebral · Diffuse -- Mild concussion -- Classic concussion -- Diffuse axonal injury



EDH v/s SDH : 

EDH v/s SDH EDH—Blood collect between bone & dura SDH – Blood collect between dura & brain

Extradural haematoma : 

Extradural haematoma Biconvex or lenticular Temporal or temporoparietal Middle meningeal artery 0.5% of all head injured pts “Lucid” interval classically 9% of those who are comatose Outcome related to status prior to surgery

Subdural haematoma : 

Subdural haematoma 30% of severe head injuries Subacute/chronic esp elderly/ETOH Trivial or no recognizable injury Tearing of bridging veins Entire surface of brain Underlying brain damage more severe Prognosis is worse than extradural

EDH : 


SDH : 


SDH : 


Contusions and intracerebral hematomas : 

Contusions and intracerebral hematomas

Intraventricular & SAH : 

Intraventricular & SAH

Chronic SDH : 

Chronic SDH

Who needs hospitalisatin? : 

Who needs hospitalisatin? Unconcious Pt/Altered sensoriom H/o LOC,convulsion,ENT bleeding, vomiting CSF tutorial or rrhinoria Palpable depressed # or head deformation Pediatric,Geriatric,Alcoholic,Unknown,Unattended K/c/o Epilepsy

Who needs hospitalization? : 

Who needs hospitalization? Focal neurological deficit (limb weakness,speech problem, isolated or multiple CN palsy/paresis etc) RTA in which death of accompanying person



Diagnostic Tool : 

Diagnostic Tool X- ray skull Ap/La CT brain plain- brain window - bone window - 3D CT MRI brain plain

X-ray skull : 

X-ray skull Almost Absolute(teaching institutation,health care center, where the CT scan not available) Help to diagnosis- depressed # - liner # - pneumocranium - pneumoventrical - pond”s # - sutural diathesis - foreign body

CT- Scan : 

CT- Scan Absolute indication- - pt unconscious / altered sense - focal neurological deficit - overt signs of HI- panda’s sign - battle's sign - palpable depressed # - obvious / continuous ENT bleeding - CSF ottorhia or rhinorrhoea - convulsion - positive x-ray skull finding

MRI : 

MRI Useful – brain stem injuries - CN evaluation - DAI( Diffuse Axonal Injuries) - to evaluate posterior fosse structure - work – up of chronic condition


MANAGEMENT Of MILD HEAD INJURY Definition: Patient is awake and may be oriented (GCS 14-15) History - Name, age, sex, race, occupation - Mechanism of injury - Time of injury - Loss of consciousness immediately post injury - Subsequent level of alertness - Amnesia: Retrograde, ante grade - Headache: Mild. Moderate. Severe - Seizures


MANAGEMENT Of MILD HEAD INJURY General examination to exclude systemic injuries Limited neurological examination Cervical spine and other x-rays as indicated . Blood-alcohol level and urine toxicology screen CT scan of the head is ideal in all patients except completely asymptomatic and neurologically normal patients


MANAGEMENT Of MILD HEAD INJURY Observe in or Admit to Hospital · No CT scanner available · Abnormal CT scan · All penetrating head injuries · History of loss of consciousness - Deteriorating level of consciousness · Moderate to severe headache - Significant alcohol/drug intoxication · Skull fracture · CSF leak rhinorrhea or otorrhea · Significant associated injuries · No reliable companion at home · Unable to return promptly · Amnesia

MRI finding of diffuse axonal injuries : 

MRI finding of diffuse axonal injuries

Post mortem specimens : 

Post mortem specimens

Mechanism of diffuse axonal injuries : 

Mechanism of diffuse axonal injuries

Pupillary changes : 

Pupillary changes

Operative management : 

Operative management

Stair case of ICP control : 

Stair case of ICP control

Management of HI Pt : 

Management of HI Pt ---- Medical Management. --- Surgical Management

Medical (non surgical) Management : 

Medical (non surgical) Management Head up position– 30 IV fluids Hyperventilation Manitol Furosemide (Lasix) Steroids Barbiturates Anticonvulsant

IV Fluids : 

IV Fluids Dehydration is - more harmful. Not to use hypotonic fluids. Use of glucose containing fluids can result in hyperglycemia, It is recommended that a solution of normal saline or Ringer’s lactate solution be used for resuscitation.

Hyperventilation : 

Hyperventilation Hyperventilation should be used cautiously, Hyperventilation acts by reducing PC02 and causing cerebral vasoconstriction. This reduction in intracranial volume helps reduce intracranial pressure. General, it is preferable to keep the PC02 at :30 mm Hg or above.

Mannitol : 

Mannitol Hypertonic Solutions. Maximal pressure reduction is obtained at an average of 90 min post injection beneficial effects of mannnitol - reduce CSF production - antioxidant properties - reduce blood viscosities - open the blood brain barrier - increase capillary diameter - beneficial effect on cardiac function

Furosemide : 

Furosemide used in conjunction with Mannitol A dose of 0,3 to .5 mg/kg of furosemide given intravenously is reasonable. Give after 45 min after mannitol

Steroids : 

Steroids studies to date have not demonstrated any beneficial effect in controlling increased ICP or improving outcome from severe head injury Therefore, steroids are not recommended in the management of acute head injury.

Barbiturates : 

Barbiturates barbiturates are effective in reducing intracranial pressure refractory to other measures.

Anticonvulsants : 

Anticonvulsants occurs in about 5% of all patients admitted to the hospital with closed head injuries and in 15% of those with severe head injuries. Three main factors are linked to a high incidence of late epilepsy (I) early seizures occurring within the first week, (2) an intracranial hematoma, or (3) a depressed skull fracture.


SURGICAL MANAGEMENT Scalp Wounds depressed Skull Fracture. Intracranial mass Lesions

Diffuse axonal injuries : 

Diffuse axonal injuries produced by acceleration-deceleration forces. is the most common type of head injury mild concussion classic cerebral concussion Diffuse axonal injury (DAI)

Prognostic Factors : 

Prognostic Factors Younger have better out come then older Focal brain injuries have better out come then diffuse injuries. In focal injuries EDH having better out come then SDH. Bilateral equal & reacting pupil have better out come then unequal reacting/non reacting pupil,bilateral dilated fixed pupil Motor response– pt localized pain have better out come then pt decerebrate.

conclusions : 

conclusions HI commonest cause of morbidity Preventable cause of death and the commonest among young Prompt and proper prehospital care saves golden hours and improves outcome of trauma victim Recent advance in neurological imaging has improved outcome Icu care should not be critical but also comprehensive Physiotherapy and rehabilitation are vital to management of trauma patients

Slide 86: 

? Questions

Summary : 

Summary Common cases – ABC approach to prevent further harm Low threshold for senior assistance Brain vs head : CT Management – other injuries “Minor” misnomer & documentation



Slide 89: 

Lucid interval (loo-sid in-ter-văl) n. temporary recovery of consciousness after a blow to the head, before relapse into coma. It is a sign of intracranial arterial bleeding. A lucid interval is especially indicative of an epidural hematoma. An estimated 20 to 50% of patients with epidural hematoma experience such a lucid interval. The lucid interval occurs after the patient is knocked out by the initial concussive force of the trauma, then lapses into unconsciousness again after recovery when bleeding causes the hematoma to expand past the point at which the body can no longer compensate

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