Head injuries

• A head injury is any trauma that leads to injury of the scalp, skull, or brain. These injuries can range from a minor bump on the skull to a devastating brain injury.

• Head injury can be classified as either closed or penetrating.

• In a closed head injury, the head sustains a blunt force by striking against an object

• In a penetrating head injury, an object breaks through the skull and enters the brain. (This object is usually moving at a high speed like a windshield or another part of a motor vehicle.)

• Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life.

• In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.

Pathophysiology• Direct trauma.• Cerebral contusion.• Intracerebral shearing.• Cerebral edema.• I.C.H• Hydrocephalus

Traumatic Head Injury

Cerebral Edema• Cellular response to injury

– Primary injury

– Secondary injury• Hypoxic-ischemic injury

– Injured neurons have increased metabolic needs

– Concurrent hypotension and hypoxemia

– Inflammatory response

The main factors which determine the severity of cerebral injury are:

• Distortion of the brain.• Mobility of brain in relation to skull

and meninges.• Configuration of interior of skull.• Deceleration and acceleration.• The pre-existing state of brain

(elderly).

Brain injury:– Concussion.– Temporary

dysfunction which resolves after a variable period

– Amnesia is common

Contusion & Laceration

•Small areas of hemorrhages

•Usually produce neurological deficits that persist for longer than 24 hours

Diffuse axonal head Diffuse axonal head injuryinjury

•As a result of mechanical shearing following deceleration, causing disruption and tearing of axons

The Secondary pathology:• Intracranial :

– Brain swelling, oedema.– Necrosis. Ischemia.– Hematoma.– Metabolic or endocrine disturbances.– Coning.– Coup & Counter-coup.– Infection– Epilepsy

• Extracranial :– Resp. failure, increase CO2.– Systemic B/P – Fluid, isotonic.– Temperature

Skull fractures• Simple fracture.• Comminuted linear fracture of the vault.• Skull base fracture.• Depressed fracture. by: -falling objects. -Assault with a heavy blunt tool. -Missile injury. -R.T.A

Skull base fracture• Diagnosed on clinical bases. • They often result in CSF leak.• Rhinorrhoea• Anosmia • C-C fistula• Periorbital hematoma• CSF otorrhoea • Battle`s sign

• Compound depressed fracture:– Antibiotics.– Anti tetanus

prophylaxis.– Surgery. Urgent.

• Closed depressed fracture

Closed depressed fracture Indication of surgery:

• Dural tear• Brain compression...

(Dural venous sinuses.)

• Cosmetic.

Missile injuries:• Scalp injury.• Depressed skull fracture.• I.C.H.• Brain injury.

Management of Traumatic Head Injury

• Maximize oxygenation and ventilation

• Support circulation / maximize cerebral perfusion

pressure

CPP=MSP-ICP

• Decrease intracranial pressure

• Decrease cerebral metabolic rate

Monitoring

• Serial neurologic examinations

• Circulation / Respiration

• Intracranial Pressure• Radiologic Studies • Laboratory Studies

Circulatory Support: Maintain Cerebral Perfusion Pressure

0

1

2

3

4

5

6

Outcome

GoodModerateSevereVegetativeDead

Number of Hypotensive Episodes

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

Lowering ICP

• Evacuate hematoma• Drain CSF

– Intraventricular catheters use is limited by degree of edema and ventricular effacement

• Craniotomy– Permanence, risk of infection, questionable

benefit

Brain Blood

CSF MassBone

• Reduce edema• Promote venous return• Reduce cerebral metabolic rate• Reduce activity associated with

elevated ICP

Management on head injuries• Minor head injury

• For a mild head injurymild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours.

• The symptoms of a serious head injuryserious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness

Indications for admission to hospital:Indications for admission to hospital:• Loss of consciousness.• Persistent drowsiness.• Focal neurological deficit.• Skull fracture.• Persisting nausea & vomiting• Elderly & infant.• W.

• Signs of deterioration:– Becomes unusually drowsy– Develops a severe headache or stiff neck– Vomits more than once– Loses consciousness (even if brief)– Behaves abnormally

• If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.

Management

• Observation.• Bed elevated 20.• Mild fluid restriction.

Severe head injury• It depends on the patient’s neurological

state and the intracranial pathology resulting from the trauma.

• Clinical assessment and CT scan• Evacuation of any hematomas

• If there is no surgical lesion, or following the operation:

– Observation and GCS chart– Decrease intracranial brain swelling

• Airway management• Elevation of the head of the bed 20º• Fluid and electrolyte balance• Blood replacement with colloid or blood and

not crystalloid• No steroids

– Management of conditions resulted from head injury

• Severe hyponatraemia due to excessive fluid intake or inappropriate excessive secretion of ADH

• Hypernatraemia due to inadequate fluid intake.

• Diabetes insipidus

• Temperature control, pyrexia due to hypothalamic damage or traumatic SAH or infection or from CSF leak and meningitis

– Nutrition:• During the initial 2-3 days the fluid therapy

will include 1.5-2 liters of 5% dextrose• After 3-4 days by nasogastric feeding

– Routine care of the unconscious patient, bowel, bladder and skin.

– Intracranial monitoring in more severe cases.