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Head Injury
Dr Mohamed EL Hady.
Senior Neurosurgeon Specialist
K S H
Head Injury
44%
5%
21%
11%
6%
12% 1%
CARS
MOTORBIKES
DOMESTIC
WORK
SPORTS
OTHER CAUSES
UNKNOWN
Causes
Head Injury
 Any trauma to the
 Scalp
 Skull
 Brain
 Head trauma includes an alteration in
consciousness.
 Common major trauma
 4 million people experience head trauma
annually
 Severe head injury is most frequent cause of tr...
Head Trauma
 Usually signifies craniocerebral trauma
 Includes alteration in consciousness
 High potential for poor out...
Consciousness
 State depends on intact cerebral
hemispheres
 Reticular activating system (RAS) in the brain
stem midbrai...
RAS is located in
brain stem
RAS
Unconsciousness
 An abnormal state in which patient is
unaware of self or environment
 Can be for very short time to lon...
Different Types of Injury
Head Injury
Cranial Injury
Brain Injury
Head Injuries
Scalp wound
• Highly vascular, bleeds briskly
 Shock: child may develop
 Shock: adult another cause
• Mana...
Skull fracture
• Linear nondisplaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Manage...
Cranial Injury
 Trauma must be extreme to cause fracture
 Linear
 Depressed
 Open
 Impaled Object
 Basal Skull
 Unprotected
 Spaces weaken
structure
 Relatively
easier to fracture
Cranial Injury
 Basal Skull Fracture Signs
 Battle’s Signs
 Retroauricular Ecchymosis
 Associated with fracture of
aud...
Basilar Skull Fracture
Battle’s sign Raccoon eyes
15Head Trauma -
Raccoon eyes
Cranial Injury
 Basilar Skull Fracture
 May tear dura
 Permit CSF to drain
through an external
passageway
 May mediate...
Mechanism of injury
Non- missile or closed head injury
Acceleration – decelaration
Coup - counter coup
191919
Acceleration
o Direct blow to the head
o Skull moves away from force
o Brain rapidly accelerates from stationary to...
202020
Deceleration
o Head impacts to a stationary object (e.g., car
windshield)
o Moving skull stops motion almost immedi...
212121
Coup/Contracoup
Injury resulting from
rapid, violent
movement of brain is
called coup and
contracoup. This action
i...
Direct Brain Injury Types
 Coup
 Injury at site of
impact
 Contrecoup
 Injury on
opposite side
from impact
Mechanism of injury
Missile or penetrating
injuries
Crainial Injuries
Penetrating trauma
24Head Trauma -
Bullet fragments
Head Trauma - 26
Forces that cause skull fracture
can also cause brain injury.
Brain Injury
 As defined by the National Head Injury
Foundation
 “a traumatic insult to the brain capable of
producing p...
Focal brain injury
Brain contusion
Bruises on the brain
Brain contusion
 Contusion – bruising of brain tissue
 Has area of necrosis infarction and
hemorrhage
 Often from coup ...
Focal brain injury
•Blood between skull and
duramater
•Arterial bleed
•period of lucency
•relatively uncommon
•present in ...
Focal brain injury
 Epidural hematoma
 Comes from bleeding between dura and inner
surface of the skull
 Will be unconsc...
Focal brain injury
Subdural hematoma
> Between the dura mater and the piaarachnoid mater
> Occurring in approximately 30% ...
Subdural Hematoma
- - - Usually bleeding is from veins, so bleeding is
GENERALLY slower than epidurals
 CAN be from arte...
Focal brain injury
Intracerebral hematoma
Can even appear 24 hours
following initial insult
Traumatic Subarachnoid Hemorrhage
 Most common CT finding in moderate to severe
TBI
 If isolated head injury, may presen...
Traumatic Subarachnoid Hemorrhage
Brain Injury
Response to injury
• Swelling of brain
 Vasodilatation with increased blood volume
 Increased ICP
• Decreas...
Hurgada Red Sea Egypt
 Cushing’s Reflex
 Increased BP
 Bradycardia
 Irregular respirations
Signs & Symptoms
of Brain Injury
Vomiting
 Witho...
 Pathophysiology of Changes
 Frontal Lobe Injury
 Alterations in personality
 Occipital Lobe Injury
 Visual disturban...
Minor Head Trauma
 Concussion –patient may not lose
consciousness
 Will be a brief change in LOC, patient may
not rememb...
Post Concussion Syndrome
 Persistent headache
 Lethargy
 Personality changes
 Short attention span
 Decreased short-t...
Clinical Manifestations of head injury
 Change in level of consciousness is the
most sensitive and important indicator of...
Clinical Manifestations
 Headache
 From compression on the walls of cranial nerves,
arteries and veins
 Worse in the mo...
Clinical Manifestations
 Vomiting
 NOT preceded by nausea- “unexpected”
 May be projectile
Clinical Manifestations
 Ocular signs
 Pupil changes are from pressure on third cranial
nerve
 Pupils become sluggish, ...
Clinical Manifestations
 Decrease in motor function
 May have hemi paresis or hemiplegia
 May see posturing – either de...
Decerebrated and Decorticted
Diagnostic Tests
 CT
 MRI
 Transcranial Doppler studies
 Looking for vasospasm
 EEG
 No lumbar puncture if there is ...
Diagnostic Tests
 Cervical spine x-ray
 You must see from 1 – 7 to see that they have no
injury
 Glasgow Coma Scale (GC...
Glasgow coma scale
 First described in 1974 by Graham Teasdale
and Bryan J. Jennett
Lancet 1974, 2:81
Glascow Coma Scale
 Used to document assessment in three areas
 Eyes opening
 Verbal response
 Motor response
 Normal...
Glasgow coma scale
Minor Head Injury: 13-15
Moderate Head Injury: 9-12
Severe Head Injury (Coma): <= 8
Categorize of head injury
Other Assessment
 Assess bodily function including
respiratory,and circulatory
 Pupil checks – are pupils equal and how ...
Alexandria Egypt
Principles of emergency management
 First priority is -
 Ventilation
 Circulation
 Stabilize cervical spine
 Limited ...
Emergency Management-Initial
 Airway
 Stabilize cervical spine
 Oxygen administration
 IV access (2 large bore cathete...
Secondary Trauma Survey
 After patient relatively stable
 Look for coexisting other organ injuries
 Complete neurologic...
Drug Therapy
 Mannitol – Rapid short acting diuretic that
decreases ICP. Decreases total brain water
content
 Watch flui...
Drug Therapy
 Barbiturates – causes decrease in
metabolism and ICP. Causes reduction in
cerebral edema and blood flow to ...
management
 Treatment principles
 Prevent secondary injury in the brain
 Timely diagnosis
 Surgery if necessary
 Cran...
Nutrition
 Patient need higher amounts of glucose to
survive.
 Will need nutritional support quickly.
 Watch sodium if ...
Nutrition
 Fluid balance is controversial
 Do not want too dry
 Keep normavolemic
 Give saline either .45% or normal s...
Laboratory Work
 ABGs regularly
 Electrolytes daily
Rehab
 Most head trauma requires rehab
 Some rehab units do coma management
 Patient may have trouble swallowing and
ne...
Elderly
 At risk for head trauma from falls
 Be alert if patient has fallen and is taking
anticoagullants
Head injury
Head injury
Head injury
Head injury
Head injury
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Head injury

  1. 1. Head Injury Dr Mohamed EL Hady. Senior Neurosurgeon Specialist K S H
  2. 2. Head Injury 44% 5% 21% 11% 6% 12% 1% CARS MOTORBIKES DOMESTIC WORK SPORTS OTHER CAUSES UNKNOWN Causes
  3. 3. Head Injury  Any trauma to the  Scalp  Skull  Brain  Head trauma includes an alteration in consciousness.
  4. 4.  Common major trauma  4 million people experience head trauma annually  Severe head injury is most frequent cause of trauma death  At Risk population  Males 15-24 males 2x as likely as women  Infants  Young Children  Elderly Head Injuries
  5. 5. Head Trauma  Usually signifies craniocerebral trauma  Includes alteration in consciousness  High potential for poor outcome  Death at injury  Death within 2 hours after injury  Death 3 weeks after injury
  6. 6. Consciousness  State depends on intact cerebral hemispheres  Reticular activating system (RAS) in the brain stem midbrain hypothalamus and thalamus  Impairment on conscious level occurs due to any lesions in the cerebral hemispheres or in the (RAS)
  7. 7. RAS is located in brain stem RAS
  8. 8. Unconsciousness  An abnormal state in which patient is unaware of self or environment  Can be for very short time to long term coma  Care is designed to  Determine the cause  Maintain bodily functions  Support vital functions  Protect patient from injury
  9. 9. Different Types of Injury Head Injury Cranial Injury Brain Injury
  10. 10. Head Injuries Scalp wound • Highly vascular, bleeds briskly  Shock: child may develop  Shock: adult another cause • Management  No unstable fracture: direct pressure, dressings  Unstable fracture: dressings, avoid direct pressure 10Head Trauma -
  11. 11. Skull fracture • Linear nondisplaced • Depressed • Compound Suspect fracture • Large contusion or darkened swelling Management • Dressing, avoid excess pressure • Before operating Head Injuries 11Head Trauma -
  12. 12. Cranial Injury  Trauma must be extreme to cause fracture  Linear  Depressed  Open  Impaled Object
  13. 13.  Basal Skull  Unprotected  Spaces weaken structure  Relatively easier to fracture
  14. 14. Cranial Injury  Basal Skull Fracture Signs  Battle’s Signs  Retroauricular Ecchymosis  Associated with fracture of auditory canal and lower areas of skull  Raccoon Eyes  Bilateral Periorbital Ecchymosis  Associated with orbital fractures
  15. 15. Basilar Skull Fracture Battle’s sign Raccoon eyes 15Head Trauma -
  16. 16. Raccoon eyes
  17. 17. Cranial Injury  Basilar Skull Fracture  May tear dura  Permit CSF to drain through an external passageway  May mediate rise of ICP  Evaluate for“Halo” sign
  18. 18. Mechanism of injury Non- missile or closed head injury Acceleration – decelaration Coup - counter coup
  19. 19. 191919 Acceleration o Direct blow to the head o Skull moves away from force o Brain rapidly accelerates from stationary to in- motion state causing cellular damage Acceleration 19
  20. 20. 202020 Deceleration o Head impacts to a stationary object (e.g., car windshield) o Moving skull stops motion almost immediately o However, brain, floating in cerebral spinal fluid (CSF), briefly continues moving in skull towards direction of impact, resulting in significant forces that damage cells Deceleration 20
  21. 21. 212121 Coup/Contracoup Injury resulting from rapid, violent movement of brain is called coup and contracoup. This action is also referred to as a cerebral contusion. o Coup: an injury occurring directly beneath the skull at the area of impact o Contracoup: injury occurs on the opposite side of the area that was impacted Coup injury Contracoup injury 21
  22. 22. Direct Brain Injury Types  Coup  Injury at site of impact  Contrecoup  Injury on opposite side from impact
  23. 23. Mechanism of injury Missile or penetrating injuries
  24. 24. Crainial Injuries Penetrating trauma 24Head Trauma - Bullet fragments
  25. 25. Head Trauma - 26 Forces that cause skull fracture can also cause brain injury.
  26. 26. Brain Injury  As defined by the National Head Injury Foundation  “a traumatic insult to the brain capable of producing physical , intellectual, emotional, social and vocational changes.”
  27. 27. Focal brain injury Brain contusion Bruises on the brain
  28. 28. Brain contusion  Contusion – bruising of brain tissue  Has area of necrosis infarction and hemorrhage  Often from coup - contrecoup injury  Seizures are common after contusion
  29. 29. Focal brain injury •Blood between skull and duramater •Arterial bleed •period of lucency •relatively uncommon •present in 1% of all head-injured patients Epidural hematoma
  30. 30. Focal brain injury  Epidural hematoma  Comes from bleeding between dura and inner surface of the skull  Will be unconscious, then awake, and then deteriorate ( lucid interval )  Headache, nausea and vomiting  Needs surgical intervention to prevent brain herniation and death
  31. 31. Focal brain injury Subdural hematoma > Between the dura mater and the piaarachnoid mater > Occurring in approximately 30% of severe head injuries
  32. 32. Subdural Hematoma - - - Usually bleeding is from veins, so bleeding is GENERALLY slower than epidurals  CAN be from arteries and these require IMMEDIATE removal  Administration of anticoagulants is one of the causes of CHRONIC TYPES esp. in the elderly.
  33. 33. Focal brain injury Intracerebral hematoma Can even appear 24 hours following initial insult
  34. 34. Traumatic Subarachnoid Hemorrhage  Most common CT finding in moderate to severe TBI  If isolated head injury, may present with headache, photophobia and meningismus  The outcome depends on the Size of bleed  Timing of CT  Nimodipine reduces death and disability by 55%
  35. 35. Traumatic Subarachnoid Hemorrhage
  36. 36. Brain Injury Response to injury • Swelling of brain  Vasodilatation with increased blood volume  Increased ICP • Decreased blood flow to brain  Perfusion decreases  Cerebral ischemia ( hypoxia) 39Head Trauma -
  37. 37. Hurgada Red Sea Egypt
  38. 38.  Cushing’s Reflex  Increased BP  Bradycardia  Irregular respirations Signs & Symptoms of Brain Injury Vomiting  Without nausea  Projectile Body temperature changes Changes in pupil reactivity Decorticate posturing
  39. 39.  Pathophysiology of Changes  Frontal Lobe Injury  Alterations in personality  Occipital Lobe Injury  Visual disturbances  Cortical Disruption  Reduce mental status or Amnesia  Retrograde  Unable to recall events before injury  Antegrade  Unable to recall events after trauma  “Repetitive Questioning”  Focal Deficits  Hemiplegia, Weakness or Seizures Signs & Symptoms of Brain Injury
  40. 40. Minor Head Trauma  Concussion –patient may not lose consciousness  Will be a brief change in LOC, patient may not remember the event and will have headache  Post-concussion syndrome is 2 weeks to 2 months after injury
  41. 41. Post Concussion Syndrome  Persistent headache  Lethargy  Personality changes  Short attention span  Decreased short-term memory  When patient is discharged after concussion nurse should instruct family on what to watch for and when to call Dr.
  42. 42. Clinical Manifestations of head injury  Change in level of consciousness is the most sensitive and important indicator of neuro status  May be pronounced or subtle  Early signs may be nonspecific: restlessness, irritability, generalized lethargy
  43. 43. Clinical Manifestations  Headache  From compression on the walls of cranial nerves, arteries and veins  Worse in the morning  Straining and movement makes worse
  44. 44. Clinical Manifestations  Vomiting  NOT preceded by nausea- “unexpected”  May be projectile
  45. 45. Clinical Manifestations  Ocular signs  Pupil changes are from pressure on third cranial nerve  Pupils become sluggish, unequal. This is because of brain shift. May also be pressure on other cranial nerves
  46. 46. Clinical Manifestations  Decrease in motor function  May have hemi paresis or hemiplegia  May see posturing – either decorticate or decerebrate  Decerebrate – more serious from damage in midbrain and brainstem  Decorticate – from interruption of voluntary motor tracts
  47. 47. Decerebrated and Decorticted
  48. 48. Diagnostic Tests  CT  MRI  Transcranial Doppler studies  Looking for vasospasm  EEG  No lumbar puncture if there is IICP because sudden release of pressure can cause brain to herniate  ABG’s – keep O2 at 100% and PCO2 as related to ICP (25-35)
  49. 49. Diagnostic Tests  Cervical spine x-ray  You must see from 1 – 7 to see that they have no injury  Glasgow Coma Scale (GCS)
  50. 50. Glasgow coma scale  First described in 1974 by Graham Teasdale and Bryan J. Jennett Lancet 1974, 2:81
  51. 51. Glascow Coma Scale  Used to document assessment in three areas  Eyes opening  Verbal response  Motor response  Normal is 15 and less than 8 indicates coma
  52. 52. Glasgow coma scale
  53. 53. Minor Head Injury: 13-15 Moderate Head Injury: 9-12 Severe Head Injury (Coma): <= 8 Categorize of head injury
  54. 54. Other Assessment  Assess bodily function including respiratory,and circulatory  Pupil checks – are pupils equal and how they react to light  Extremity strength  Corneal reflex test
  55. 55. Alexandria Egypt
  56. 56. Principles of emergency management  First priority is -  Ventilation  Circulation  Stabilize cervical spine  Limited time for initial evaluation of neurological status  Treatment of hemorrhagic shock takes precedence over neurosurgical procedures
  57. 57. Emergency Management-Initial  Airway  Stabilize cervical spine  Oxygen administration  IV access (2 large bore catheters), LR or NS  Control external bleeding with pressure  Assess for rhinorrhea, otorrhea, scalp wounds  Remove clothing
  58. 58. Secondary Trauma Survey  After patient relatively stable  Look for coexisting other organ injuries  Complete neurological examination  Severity of head injury classified by GCS score.
  59. 59. Drug Therapy  Mannitol – Rapid short acting diuretic that decreases ICP. Decreases total brain water content  Watch fluids and electrolytes closely  Don’t give in cases of renal failure or if serum osmolality increased
  60. 60. Drug Therapy  Barbiturates – causes decrease in metabolism and ICP. Causes reduction in cerebral edema and blood flow to brain.  Watch for hangover effects and drowsiness. Side effects make it harder to check LOC. Watch for constipation – do not want patient straining. Skeletal muscle paralyses may be used (Pavulon) Antiseizure drugs - Dilantin
  61. 61. management  Treatment principles  Prevent secondary injury in the brain  Timely diagnosis  Surgery if necessary  Craniotomy  Craniectomy  Cranioplasty  Burr-hole
  62. 62. Nutrition  Patient need higher amounts of glucose to survive.  Will need nutritional support quickly.  Watch sodium if on Mannitol – may need to give additional salt.  Also may need additional free water if dehydrated
  63. 63. Nutrition  Fluid balance is controversial  Do not want too dry  Keep normavolemic  Give saline either .45% or normal saline – not glucose to help prevent additional cerebral edema
  64. 64. Laboratory Work  ABGs regularly  Electrolytes daily
  65. 65. Rehab  Most head trauma requires rehab  Some rehab units do coma management  Patient may have trouble swallowing and need speech therapy  Patient may agitate easily and act out sexually  May be a flight risk and have to be in a locked ward until passes through the agitation phase
  66. 66. Elderly  At risk for head trauma from falls  Be alert if patient has fallen and is taking anticoagullants

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