Head Injuries

Presented to Dr.Gehan Moussa Presented by Ahmed Wagdi

2012-2013
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Head Injuries
A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury. Head injury is classified as either closed or open (penetrating). A closed head injury means you received a hard blow to the head from striking an object, but the object did not break the skull. An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

Types of Head Injuries:

Traumatic brain injuries are commonly categorized according to severity: 1) Mild Traumatic Brain Injury The most common type of brain injury (75%-85%) NO loss of consciousness or a brief (<15 minutes) Neurological exam is usually normal. Patient recovers within 6-8 weeks, often within hours or days. Mild traumatic brain injury often do not receive medical followup because the injury was deemed "mild".
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2) Moderate Brain Injury Loss of Consciousness /Coma between 20-30 minutes to 24 hours, followed by a few days or weeks of confusion. EEG/CAT/MRI is positive for brain injury. Patient with moderate brain injury have long-term with difficulties (50%) There is clear evidence that an injury has occurred. 3) Severe Traumatic Brain Injury Prolonged loss of consciousness or coma of days, weeks, or longer. 80% of patient with severe brain injury have multiple impairments in functioning. Patient requires weeks, months and years of therapy to regain skills and regain the function. Progress may be very slow.

Open Head Injuries

Is a head injury in which the Dura mater, the outer layer of the Meninges, is breached. Penetrating injury can be caused by highvelocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. A perforating head injury is one in which the object passes through the head and leaves an exit wound. Head injuries caused by penetrating trauma are serious medical emergencies and may cause permanent disability or death.

Mechanism of Injury
Injury from high-velocity missiles, injuries may occur from initial laceration and crushing of brain tissue by the projectile. High-velocity objects create rotations and create a shock wave that cause stretch injuries, forming a cavity that is 3 to 4 times greater in diameter than the missile itself. The tissue that was compressed during cavitations remains injured. Destroyed brain tissue may either be ejected from entrance or exit wounds or compression against the sides of the cavity formed.

 Low-velocity objects usually cause penetrating injuries in the regions of the skull's temporal bones or orbital surfaces, as bones are thinner and more able to break. Damage from lower-velocity penetrating injuries is restricted to the tract of the stab wound, because the lower-velocity object does not create as much cavitations.

Open head injuries differ depending on the type of skull fracture, of which there are :
a) Linear Skull Fracture Linear skull fracture, or a crack in the skull, presents about 69% percent of all open head injuries. Depending on the location of the injury, patients with linear skull fractures may suffer a variety of complications, including blood vessel damage and leakage of cerebrospinal fluid from the nose and ears. Patients with significant brain swelling may suffer from linear skull fractures as a result of the pressure on the skull. b) Depressed Skull Fracture Depressed skull fractures are often the result of a severe blow to the head with a blunt object. Broken skull fragments from depressed skull fractures penetrate or compress brain tissue and can cause severe brain damage. A depressed skull fracture occurs when a piece of skull is pushed toward the inside of the skull. Surgery may be required to elevate the depressed fragment. Major causes of head injuries:
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Road traffic accidents Trauma Sports injury Assault & civil violence Industrial accidents

Complications : Most common is meningitis (Infection) Loss of consciousness & Confusion CSF leakage from ear or nose Diffuse axonal injury Heterotopic Ossification Respiratory complications Contractures Paralysis Coma Death

Severity of Head Injuries

Is determined by Glasgow Coma Test (GSC) Length of unconsciousness (time in a coma) Length of post-traumatic amnesia (PTA)
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 Grades of Consciousness
Coma: there is no response to any stimulus. Semi-coma: Patient responds to pain and vigorous shake. Deep and superficial reflexes are present. Stupor: Patient is irritable and unco-operative and no spontaneous activity. Confusion: Patient cant think clearly or understand surroundings.

Glasgow Coma Scale (GCS)

Severity of head injuries is most commonly classified by Glasgow Coma Scale (GCS) score, which generates a numerical summed score for eye, motor, and verbal abilities. Traditionally, a score of 13-15 indicates mild injury, a score of 912 indicates moderate injury, and a score of 8 or less indicates severe injury. In the last few years, however, some studies have included those patients with scores of 13 in the moderate category, while only those patients with scores of 14 or 15 have been included as mild. Concussion and mild head injury are generally synonymous.

Common Functional Disabilities

Physical Changes: 1-Motor Skills and Balance 2-Hearing Loss 3-Vision Affection
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4-Spasticity or Tremors 5-Speech Disorders 6-Fatigue or Weakness 7-Seizures 8-Taste and Smell Affection Changes in Cognition and Thinking 1-Memory and Attention Impairment 2-Reduce Speed of Information Process 3-Decreased Awareness 4-Receptive and Expressive Aphasia Inability to understand what is being said or what is read 5-Executive Skills (Problem solving, organizational skills, etc)

Changes in Personality and Behavior 1-Depression 2-Substance Use and Abuse 3-Social and Emotional Problems

Treatment
Surgical treatment Physiotherapy

Surgical treatment

 The role of operative surgery in these patients is limited to correcting bone deformity, stopping bleeding and relieving intracranial tension.

Physiotherapy
Inpatient Role (ICU) (Coma) Outpatient Role

Role of Physiotherapy during Coma Physical Therapy Goals

1-Maintain normal ventilation and oxygenation. 2-Maintain musculoskeletal system within functional limit. 3-Improve Circulatory system function 4-Maintain Neurological system within functional limit

Pulmonary System
1- Intubated Patient :

Modified postural drainage positions a) Turn patient to both sides and manually hyperventilate the patient using the ambu bag. b) Use pulmonary hygiene techniques to mobilize Secretions such as vibration, percussion, rib springs and Shaking.
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c) Endotracheal suctioning d) Position for relaxation to decreased dyspnea (the head of the bed elevated to 30 degrees and lying on well) 2- Extubated or Non-Intubated Patient: Modified postural drainage position a) Pulmonary hygiene techniques to mobilize secretion b) Use Neuro-physiological facilitation of respiration to facilitate deep breathing, increase lung volume and increase thoracic expansion. c) Use tracheal tickle technique to elicit a cough d) Side lying the prone positions are the best positions to improve oxygenation and ventilation.

Circulatory System

1. PROM 2. Elastic crepe bandage 3. Compression unit 4. Limb Elevation.

Musculoskeletal System

1. Passive ROM of upper and lower extremities including prolonged stretching.

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2. Use of splints (by keeping most joints in the neutral or functional position). Inhibitive casting or patients shoes can also be used. 3. Proper positioning for all joints of the body.

Neurological System

1. Patient must be oriented to place, person and time by health care team and family members. 2. Decrease limb spasticity keep hips flexed and abducted, or position patient in side lying. *For decerebrate posture, use asymmetric tonic reflex on affected side to decrease upper limb extended tone. *For decorticate posture, use Symmetric neck reflex to decrease flexor tone in the upper limbs and extensor tone in the lower limbs. 3. Using ice pack can also decrease limb spasticity. 4. Activities in the upright and bed mobility can be used to improve muscles tone and facilitate active movement which will provide vestibular and tactile stimulation and improve lung function. 5. Patient should be in the upright position as soon as possible (by gradually raising the head, using the tilt table or transferring patient to the chair) to prevent osteoporosis, to improve lung function. 6. Work on head and trunk control and use weight bearing activities for the upper limbs while patient is at the edge of the bed to promote equilibrium reactions and to improve muscles tone. The therapist can move the patient passively in this position to give him feeling of weight shifting.
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7. the patient is sitting at the edge of the bed, ensure that his feet are well supported to provide stimulation and feedback and to encourage some weight bearing through the lower limbs.

Role of Physiotherapy (Outpatient)

Goals of Physiotherapy: Reduce muscle spasms, pain and stiffness Improve functional abilities such as rolling, sitting, standing and walking Retrain normal patterns of movement Improve balance and coordination Improve muscle strength and range of movement Improve posture Improve positioning and alignment Improve independence and quality of life 1- Respiratory Ex To Improve Ventilation of lung 2-Position Management: Risk of pressure areas, contracture, and respiratory complications should be considered when a patient is positioned. The patient should be moved between supine and right or left side lying, if possible. Too many pillows in the bed can cause contractures. One pillow under the head is usually sufficient for comfort as too many pillows may lead to contracture of the neck flexors. Pillows placed under the knees can cause contracture of the knee flexors, preventing full extension when standing is begun. 3- Mobilization/Verticalisation Training
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 Mobilisation means bringing the patient into an upright seated position at the edge of the bed or outside the bed or to a standing position. Early mobilisation within the first 24 hours after injury reduces mortality and long-term disability 4- Prevention of Contracture (Stretching Ex) Prevention of contracture is best achieved by the application of low load prolonged stretches. If stretching is not maintaining muscle length or if contracture is already present, serial casting may need to be considered. 5- Serial Casting Serial casts are usually applied from 3 to 7 days then removed and range of motion re-measured Side effects or complications that can be caused by serial casting include: a. Pressure areas b. Circulation restriction c. Nerve compression at superficial points 6- Spasticity Management 7- ADL Training/Self-Care Training of self-care activities and activities of daily living (ADL) to patients with sensory, motor, or cognitive dysfunction. 8- Co-ordination Ex
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9- Bladder Control Training 10- Balance and Gait Training By vestibular rehabilitation techniques to compensate for balance disorders Stairs Start walking up four stairs. Relax 10 seconds. Slowly turn around and walk back to your starting position. Relax 10 seconds. Log Rolls Lay down on back on bed. Extend legs and arms; put arms over your head. Rotate body as quickly as possible to the right and keep rolling until you

Return to the original position. Relax 10 seconds, and then roll the opposite direction. Walkers 1-Use a walker without wheels to prevent slippage 2-Place a walker in front of your body while sitting upright. 3-Hold the walker and rise slowly from seat. 4-Hold the walker for 20 secs without moving body. Fall Backs 1-Sit upright on the edge of bed with feet firmly planted on the floor 2-Quickly fall backward on back. Rotate head to the right 3-Stay in this position for one minute. Return to original upright position. Relax 10 secs.
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