Management of head injury

1. Management of
Head Injury
by:
Pawan KB Agrawal
MDGP Resident, Year II.
6th August, 2014, Wednesday.

2. Outline
►Introduction
►Assessment
►Treatment
►Other complications of head injury
►Additional care

3. Introduction
►Head injury is a frequent cause of
emergency department attendance,
accounting for approximately 3.4% of all
presentations1.
►It is the most common cause of death in
young adults (age 15–24 years) and is more
common in males than females.

4. Introduction
►Road traffic accidents (RTAs) are the most
common cause of head injury , followed by
falls and assaults1.
►Although the majority of injuries are mild,
around 10.9% are classified as moderate or
severe and many patients are left with
significant disability2.

5. Assessment
►Assessment should be done under these
three headings1.
 Mechanism of injury:
►Blunt Vs Penetrating
 Glassgow Coma Scale:
►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.

6. Assessment
 Morphology:
►Scalp: laceration, hematomas
►Skull: Vault (linear, depressed or
communited) or basilar fractures
►Intracranial: hematomas (epi/subdural,
subarachnoid or parenchymal) , contusions
and diffuse axonal injury.

7. Investigations
►CT Scan:
 Recent guidelines suggest CT in all head injury
with GCS ≤14.
 NICE guidelines for computerised tomography
in head injury
►Glasgow Coma Score (GCS) <13 at any point
►GCS 13 or 14 at 2 hours
►Focal neurological deficit
►Suspected open, depressed or basal skull fracture
►Seizure
►Vomiting > one episode

8. Investigations
 CT Scan should also be considered if
►Age > 65
►Coagulopathy (e.g. on warfarin)
►Dangerous mechanism of injury (CT within 8 hours)
►Antegrade amnesia > 30 min (CT within 8 hours)
►Electrolytes: Na/K
►Random blood sugar
►X-ray C-spine:

9. Investigations
 As per NEXUS (National Emergency X-radiography
Utilisation Group) criteria, C-spine injury can be
clinically ruled out if:
► Normal level of alertness i.e. GCS 15
► No evidence of intoxication.
► No C-spine tenderness.
► No focal neurological deficits.
► No distracting injuries (esp long bone fractures)

10. Treatment
►Minor/mild head injury1:
 Examination and a period of observation of 24
hours especially if CT is not available.
 The following criteria must be met before
discharge: the patient must have a GCS of
15/15 with no focal neurological deficit; the
patient must be accompanied by a responsible
adult and should not be under the influence of
alcohol or other drugs.

11. Treatment
► Advice must be given to return to the emergency
department if persistent or worsening headache
despite analgesia, persistent vomiting, drowsiness,
visual disturbance such as double or blurred
vision, and development of weakness or
numbness in the limbs.

12. Treatment
►Moderate/severe head injury:
►ABCDE as per primary trauma care.
►Cervical immobilization is required until
clearance obtained.
►Severe head injury also requires
intubation and is best managed in neuro-
intensive care settings even if
neurosurgical intervention is not
performed1.

13. Treatment
►Treatment should aim to avoid hypoxia
and hypotension2.
 Maintain SaO2 >97, Maintain a PaCO2 value of 4.5–
5.0 kPa.
 Maintain MAP >80 (BTF)-90 (AAGBI) mm Hg3-5.
Replace intravascular volume, avoid hypotonic and
glucose-containing solutions.
►Glucose management : Hyperglycemia
is associated with worsened outcome in a
variety of neurologic conditions including
severe TBI.6-8

14. Treatment
►Temperature management — Fever
worsens outcome after stroke and
probably severe head injury, presumably
by aggravating secondary brain injury
10.Hence, current approaches emphasize
maintaining normothermia.

15. Treatment
 Medical management of raised
intracranial pressure > 20-25 mm Hg
10 :
►Position head up 30º
►Avoid obstruction of venous drainage
from head keeping head in midline and
cervical immobilisation collar should not
obstruct venous return from the head.
►Sedation +/– muscle relaxant

16. Treatment
► Normocapnia 4.5–5.0 kPa
► Diuretics like furosemide, mannitol (0.5-1 g/kg
bd- tds) to reduce cerebral swelling.
► Seizure control: Seizures increase the brain
metabolic rate and should be controlled.
Prophylactic use of anticonvulsants reduce
seizures in the first week is recommended11-12.
► Normothermia

17. Treatment
►For intracranial hypertension refractory to
medical therapy, ventriculostomy or
decompressive craniectomy can be
employed1.

18. Treatment
► Sodium balance: Severely brain-injured
patients are susceptible to disturbances of
sodium haemostasis such as diabetes insipidus
and syndrome of inappropriate antidiuretic
hormone (SIADH).
► Barbiturates
► Steroids in severe head injury are
associated with increased mortality and
should not be used13.
► Further steps are aimed at specific
morphological injuries.

19. Treatment
 Scalp:
►Scalp laceration: debridement and
primary closure if possible.
►Scalp hematoma: Observation with
analgesics.

20. Treatment
 Skull:
► Open fractures should be considered for
debridement and subsequent closure if possible.
► But operative intervention is considered if 3,14
 skull fractures depressed greater than the thickness
of the cranium
 dural penetration
 Associated with significant intracranial hematoma
 frontal sinus involvement
 wound infection or contamination
 pneumocephalus

22. Treatment
► Depressed fractures — Patients with depressed
skull fractures are at increased risk of infection
and seizures, and prophylactic measures are
recommended 15:
 tetanus prophylaxis given as appropriate.
 prophylactic antibiotics be given for five to
seven days to prevent the risk of subsequent
CNS infection.
 anticonvulsants are often given to reduce the
risk of seizures.

23. Treatment
 Cerebrospinal fluid leaks:
► The majority of CSF leaks resolve spontaneously
within one week of injury and without CNS
complications 16,17.
► The incidence of bacterial meningitis rises
substantially if the leak persists past seven days
prophylactic antibiotics should be given in such
cases 18.

24. Treatment
 When to intervene??19
► Persistent for 7-10 days.
► Ceased leak that recurs after 7-10 days.
► Clinical evidence of large defect like herniation
of brain tissue through nostrils.
► Meningitis or brain abscess.

26. Treatment
 Intracranial hematomas:
► Consider in cases of depressed skull fractures,
focal neurological deficits including cranial nerve
palsies, ipsilateral pupillary dilatation and
contralateral paralysis, ataxia (esp in elderlies).
► Epidural hematoma —Surgical guidelines
recommend evacuation of an epidural
hematoma (EDH) if20:
 larger than 30 mL
 coma (GCS score ≤8) who have pupillary
abnormalities (anisocoria).

28. Treatment
 Subdural hematoma — Surgical
evacuation if21:
► acute SDH >10 mm in thickness
► midline shift >5 mm on CT
► GCS ≤8
► Decrease in GCS by ≥2 points from the time of
injury to hospital admission
► asymmetric or fixed and dilated pupils
► intracranial pressure measurements are
consistently >20 mmHg.

30. Treatment
 Subarachnoid haemorrhage:
►Trauma is the most common cause of
SAH followed by rupture of aneurysm.
Treated with:
 Triple H therapy: Hypervolemia,
hemodilution & hypertension.
 Nimodipine
 Statins 22.

31. Treatment
►Intracerebral hemorrhage —
Surgical evacuation of a traumatic
intracerebral hemorrhage (ICH) in the
posterior fossa is recommended if:
 significant mass effect (distortion,
dislocation, obliteration of the fourth
ventricle, compression of the basal
cisterns, or obstructive hydrocephalus) 23.

32. Treatment
►For traumatic ICH involving the cerebral
hemispheres, consensus surgical guidelines
recommend craniotomy with evacuation if24:
 the hemorrhage exceeds 50 cm3 in volume
 GCS score <8 with a frontal or temporal
hemorrhage greater than 20 cm3 with midline
shift of at least 5 mm and/or cisternal
compression on CT scan.

33. Other complications in head injury
►Cranial nerve injuries:
 Occurs in 1/3rd of patients with moderate to
severe head injury. Recovery is more likely with
injury of CN III, IV & VI and less with CN VII &
VIII19.

34. Other complications in head injury
►Post traumatic seizures:
 About one-half of early post-traumatic seizures
occur during the first 24 hours, and one-quarter
occur within the first hour 25.
 Early seizures occurring within one week are
acute symptomatic events and are more
common with intracranial hematoma, depressed
skull fracture, severe injury, and in young
children.

35. Other complications in head injury
 In patients who have not had but appear to be
at risk for early seizures, AED treatment reduces
the incidence of early seizures and may be used
because of similar concerns for secondary
complications 26,27.
 Between 17 to 33 percent of patients with early
seizures will develop epilepsy.

36. Other complications in head injury
 Recurrence of seizures without treatment is
likely, as high as 86 percent in the first two
years 28.As a result, long-term anticonvulsant
treatment is recommended for patients after an
initial late seizure.

37. Other complications in head injury
►Coagulopathy:
 Approximately one-third of patients with severe
head injury develop a coagulopathy, which is
associated with an increased risk of hemorrhage
enlargement, poor neurologic outcomes and
death 29-33.
 Severe head injury produce a coagulopathy
through the systemic release of tissue factor
and brain phospholipids into the circulation
leading to inappropriate intravascular
coagulation and a consumptive coagulopathy 34.

38. Other complications in head injury
►Coagulation parameters should be
measured in the emergency department in
all patients with severe head injury and
efforts to correct any identified
coagulopathy should begin immediately.

39. Other complications in head injury
►SIADH:
 Fluid restriction, salt administration, and
vasopressin receptor antagonists.
 Fluid restriction is a mainstay of therapy in most
patients with SIADH, with a suggested goal
intake of less than 800 mL/day 35.
 Use of hypertonic saline:
►An effective initial regimen is 100 mL of 3 percent
saline given as an intravenous bolus, which should
raise the serum sodium concentration by

40. Other complications in head injury
►approximately 1.5 meq/L in men and 2.0
meq/L in women, thereby reducing the
degree of cerebral edema. If neurologic
symptoms persist or worsen, a 100 mL bolus
of 3 percent saline can be repeated one or
two more times at ten minute intervals.

41. Other complications in head injury
►Cerebral Salt wasting
 characterized by hyponatremia and extracellular
fluid depletion due to inappropriate sodium
wasting in the urine.
 Volume repletion with isotonic saline is the
recommended therapy in CSW.

42. Additional Care
►Peptic ulcer prophylaxis
►Trophic sore prophylaxis
►Physiotherapy
►Bowel and bladder care.

43. References
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50. ►Thank You…