7. PERSONAL HISTORY
Non smoker
No history of drug addiction or
dependence.
8. PHYSICAL EXAMINATION:
1. GPE:
A middle aged gentleman, lying in bed
confused and Drowsy
His vitals are;
Pulse: 100/min
B.P: 130/80 mm of Hg
Oxygen Sat: 96%
Temp: Afebrile
Rest of GPE unremarkable.
9. NEUROLOGICAL
EXAMINATION:
GCS 13/15
Pupils – Bilaterally reactive to light
No Obvious injury on the scalp
Rest of the systemic exam ---
unremarkable
10. Investigations on the
day of admission
Xrays Skull AP and lateral views
Blood CP
BSR
18. Subdural Hematoma
A subdural hematoma (SDH)
is a form of traumatic brain
injury in which blood gathers
between the dura and the
arachnoid.
19. Pathophysiology
Unlike in epidural hematomas, SDH usually results from the tears
in veins.
Further expansion due to osmosis
In some subdural bleeds, the arachnoid layer of the meninges is
torn
Local vasoconstrictors
May be reabsorbed, a subdural hygroma may be formed
21. Risk Factors
Extreme of age
Anticogulants
Long term Alcohol Abuse
22. Clinical Features of
A history of recent head SDH
injury
Loss of consciousness or fluctuating levels of consciousness
Irritability
Seizures
Numbness
Headache (either constant or fluctuating)
Dizziness
Disorientation
Amnesia
Weakness or lethargy
Nausea or vomiting
Personality changes
Inability to speak or slurred speech
Ataxia, or difficulty walking
Altered breathing patterns
Blurred Vision
23. Extradural Hematoma Subdural Hematoma
Biconvex or lenticular Diffuse and concave
Temporal or Entire surface of brain
temporoparietal
Middle meningeal artery Tearing of bridging veins
0.5% of all head injured 30% of severe head
pts injuries
“Lucid” interval classically Underlying brain damage
more severe
Outcome related to status Prognosis is worse than
prior to surgery extradural
24. Diagnosis
It is important that a patient receive
medical assessment, including a
complete neurological examination, after
any head trauma. A CT scan will usually
detect significant subdural hematomas.
25. 8.2. Non-contrast CT Brain 8.2 Non-contrast CT Brain
Acute and subacute Subdural CT Density 72.9 HU
Hematoma
32. Management of Mild
Head Injury (GCS
14-15)
About 3% of these patients deteriorate unexpectedly,
resulting in severe neurological dysfunctions unless the
decline in mental status is noticed early
Ideally, a CT scan should be obtained in all head-injury
patients, especially if there is a history of more than a
momentary loss of consciousness, amnesia, or severe
headaches.
33. NICE guidelines for CT
in Head Injury
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
Urgent CT if none of the above but
Age > 65
Coagulopathy (e.g. on warfarin)
Dangerous mechanism of injury (CT within 8 hours)
Antegrade amnesia > 30 minutes
34. Management of Mild
Head Injury (GCS
14-15) (cont.)
At present, skull x-rays are recommended only in
penetrating head injury or when CT scanning is not
immediately available
X-rays of the cervical spine must be obtained if there is
any pain or tenderness.
35. Management of
Moderate Head
Injury(GCS 9-13)
Approximately 10% to 20% of these patients
deteriorate and lapse into coma. Therefore, they
should be managed like severely head-injured patient
They are not routinely intubated. However every
precaution should be taken to protect the airway
36. Management of severe
Head Injury (GCS 3-8)
In a comatose patient (GCS 8 or below) secure and
maintain the airway by endotracheal intubation
Moderately hyperventilate the patient to reverse
hypercarbia, maintaining the PCO2 between 25 and 35
mm Hg
Treat shock aggressively and look for its cause
(consider DPL)
Resuscitate with normal saline, Ringer’s lactate or
similar isotonic solutions without dextrose. Do not use
hypotonic solutions. Avoid both hypovolemia and over
hydration, achieving a euvolemic state.
37. Perform a neurologic examination after normalizing the
blood pressure and before paralyzing the patent. Avoid
the use of long-acting paralytic agents.
All severe and most modetate head injury patients
require a CT scan to exclude mass lesions
Search for associated injuries. Exclude cervical spine
injuries radiographically and clinically
Contact a neurosurgeon as early as possible. If a
neurosurgeon is not available at your facility, transfer
all moderately or severely head-injured patients
Frequently reassess GCS