Head injury or traumatic brain injury (TBI) occurs due to sudden trauma to the head or brain, resulting in brain

damage. It is the leading cause for disability among children and young adults. Although traumatic head injury can affect people of all ages, young adults between the age of 15 and 24 years and those above 75 years face an increased risk of head injury.

The Brain Injury Association of America adopted the following definition of TBI in the year 1986 - 'Traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment'. Causes of Head Injury A head or traumatic brain injury may be caused when an external force is sufficient enough to cause movement of the brain within the skull or causes the skull to break, thereby inducing a direct injury to the brain. The former is more likely to occur following road traffic accidents, falls, violent acts such as striking or hitting with an iron rod and sports activities. A majority of the head injuries (50%) are the result of road traffic accidents involving motorbikes, automobiles and bicycles. Pedestrians are not spared either. Transportation accidents are in fact the leading cause of head injuries in those under 75 years of age. Driving under the influence of alcohol or drugs is to a large extent responsible for such road traffic accidents (50%). In persons above the age of 75 years, falls account for a major proportion of head injuries. Other less common causes include violence, such as gunshots, firearm assaults, and child abuse. This accounts for approximately 20% of TBIs. Sports injuries are responsible for 3% of head injuries. Less commonly, conditions such as drowning, cardiac arrest can also lead to head injuries. Head Injury - Types Head injury can be classified into different types based on the location and severity. The

injury can be in one specific area of the brain (focal brain injury) or different regions of the brain may be injury of different parts of the brain) and severity of brain injury. It can range from a mild concussion to severe injuries, resulting in death of the affected individual. When a person's head is subjected to external force, it can damage the superficial skin, skull, and / or the underlying brain. Small cuts, burns and bruising represent some forms of skin injury. It is not possible to comment upon the relation between skin and brain injury. A person with injured skin over his head may or may not have a brain injury. Similarly, a person with brain injury may not have an obvious skin injury. Open And Closed Head Injuries An external force exerted over the head can be sufficient enough to fracture or displace the skull. Under such an instance, a patient is said to have contracted an open head injury. It should be remembered that the term open injury is specific to the skull and does not relate to brain damage. In closed type of brain injury, there is no damage to the skull. Based on type of force and amount of force, brain injury may be classified into different categories, as follows. Concussion: It is the most common and minor form of head injury. Ideally, concussion refers to a temporary loss of consciousness in response to head injury. Of late, the term has also been used to describe a minor injury of the head or brain, as a consequence of change in movement or sudden momentum. Contusion: Fracture of the skull can lead to a contusion. The skull is composed of bone tissue and protects the underlying brain. The inner surface of the skull is rough and hence friction caused due to movement of the brain within the skull can result in brain injury. Any bruising on the brain as a result of skull fracture is referred to as a contusion and represents a specific brain region of the brain that is swollen and mixed with blood from the damaged blood vessels. Hematoma: Damage of a blood vessel in the brain and the consequent heavy bleeding around the brain, leads to hematoma. Three different types of hematoma exist, based on the location of the bleeding, namely epidural, subdural and intracerebral hematoma. Anoxia: Anoxia refers to brain damage as a result of complete reduction in oxygen supply to the brain tissue. However, the blood supply to the brain may be adequate. Hypoxia refers to a lack of proper oxygen supply to the brain. Starved of oxygen, cells in the brain die. This kind of brain damage is seen following drowning, heart attack or in people who suffer from heavy blood loss following extensive brain injury. Second Impact Syndrome: This kind of a brain injury is seen when a person with brain injury sustains a second injury. It can happen either days or weeks following the first injury. Head Injury- Symptoms Depending on the nature of the head injury and the extent of brain damage, symptoms of head injury can either be mild, moderate or severe. Some symptoms may be seen immediately following the brain injury while others might take several days or weeks to manifest. Immediate, seen within seconds or minutes

 Loss of consciousness (In some instances, persons with head injury may remain
conscious as well)

Impaired attention, poor response to commands, speech without coherence Headache, confusion Disorientation and lack of co-ordination
The following symptoms may be seen within several hours, days or even weeks, following the accident. The presence of any of these symptoms warrants consultation with a neurologist.

Nausea/ Vomiting Vision problems Ringing in the ears (Tinnitus) Fatigue, irritability, anxiety or depression Memory retention problems Lack of attention and concentration Inability to tolerate loud noise Sensitivity to bright light Sleep Disturbances Convulsions / Seizures Coma Loss of sensation in the extremities.
Diagnosis Of Head Injury Glasgow Coma Scale: This test is routinely employed in head injury patients to assess the level of brain damage. The patient's ability to open the eyes, the verbal response of the patient and the level neurological functioning are tested. The test has a total of 15 points and the patients are rated for each of the above parameter. A score of 15 means that the patient is normal while 13 to 14 signifies a mild injury. Moderate injury rates to a score of 9 to 12 while a score of 0 is diagnostic of brain death.

Imaging Techniques Different forms of imaging modalities such as X-rays (demonstrates presence of fractures in the neck and skull), Computed Tomography/CT scan (reveals presence of bone/skull fractures, bleeding, hematoma, inflammation of the brain, and brain tumors) and Magnetic Resonance imaging (MRI) can be used in assessing the extent of head injury and damage to the brain and other vital organs. The cost associated with MRI and the non-availability of this form of imaging in all emergency wards limit the use of MRI in assessing head injury. In addition to the above-mentioned imaging techniques, cerebral angiography, electroencephalography (EEG), transcranial Doppler ultrasound, and single photon emission computed tomography (SPECT) might be used to assist in the diagnosis.

Head Injury - Treatment Treatment Of Minor Head Injuries Minor head injuries can be managed with bed rest, intravenous fluids and pain killing medication. Ice packs may be applied over the scalp to numb the pain and decrease the local swelling. In case of a small cut over the head, the doctor examines the wound to look for presence of foreign objects. If no hidden injuries or foreign objects are seen, the wound is cleansed. Local anesthetic is given over the affected area and the wound is closed with the help of sutures (stitches) or skin staples. A shot of tetanus is usually given if not given previously. Treatment Of Severe Head Injury Following severe brain injury, nearly 33% of patients recover to an optimal level following treatment. About the same percentage of patients die following the tragic incident. The rest suffer from varying levels of physical and mental disability (33%). Severe head injury is a medical emergency. Hence people with moderate to severe open or closed head injuries are admitted to the hospital for management and further observation. If the head injury leads to a significant elevation in intracranial pressure, decompression of the brain may be accomplished through insertion of a probe into the brain. Drugs for prevention of seizures may be given following brain injury. After recovery, however such seizures do not occur and usually does not require any treatment. In case of a closed head injury, a number of factors such as the location of head injury, the presence of bleeding, the nature and severity of the symptoms, the presence of other injuries are to be considered. Surgery may be needed. Nearly 50% of all head injuries may need a surgery to surgically repair the damage. In case of penetrating brain injuries, surgery may have to be done to remove the foreign object or to arrest bleeding. Following surgery, the patient may have to be strictly monitored in the intensive care unit (ICU). Once the patient recovers, the patient can be transferred to a sub acute medical care unit. Medications may be given to protect the brain and preserve brain function. The patient may then be referred to a rehabilitation unit. The rehabilitation therapy should be targeted at restoring the functionality of the individual to the maximum possible extent.

First Aid Learning to recognize a serious head injury and give basic first aid can save someone's life. Get medical help right away if the person: Becomes very sleepy Behaves abnormally Develops a severe headache or stiff neck Has pupils (the dark central part of the eye) of unequal sizes Is unable to move an arm or leg Loses consciousness, even briefly Vomits more than once For a moderate to severe head injury, take the following steps: Call 911 right away. Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR. If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head. Keep the head in line with the spine and prevent movement. Wait for medical help. Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks through the cloth, do not remove it. Place another cloth over the first one. If you suspect a skull fracture, do not apply direct pressure to the bleeding site, and do not remove any debris from the wound. Cover the wound with sterile gauze dressing. If the person is vomiting, to prevent choking, roll the person's head, neck, and body as one unit onto his or her side. This still protects the spine, which you must always assume is injured in the case of a head injury. Children often vomit once after a head injury. This may not be a problem, but call a doctor for further guidance. Apply ice packs to swollen areas. A more serious head injury that involves bleeding or brain damage must be treated in a hospital. For a mild head injury, no treatment may be needed. Be aware though, symptoms of a head injury can show up later. Follow the instructions below under Home Care. DO NOT Do Do Do Do Do Do Do NOT NOT NOT NOT NOT NOT NOT wash a head wound that is deep or bleeding a lot. remove any object sticking out of a wound. move the person unless absolutely necessary. shake the person if he or she seems dazed. remove a helmet if you suspect a serious head injury. pick up a fallen child with any sign of head injury. drink alcohol within 48 hours of a serious head injury.

When to Contact a Medical Professional

Call 911 right away if: There is severe head or face bleeding The person is confused, tired, or unconscious The person stops breathing You suspect a serious head or neck injury, or the person develops any signs or symptoms of a serious head injury Home Care Friends or family may need to keep an eye on adults who have been injured after they are released from the emergency room or office. If the person is an athlete, follow the health care provider's instructions about when the person can return to sports. Parents or caregivers of children will need to learn how to keep an eye on the child after a head injury. Follow the health care provider's instructions on when the child can go back to being active and playing sports. After even a mild concussion do not do activities that can cause further head injury. Avoid tasks that require concentration or complicated thinking. These include reading, homework, preparing reports, and other kinds of brain stimulation. Also avoid bright lights and loud sounds. These can overstimulate the brain. Your health care provider can tell you more. Follow-Up

Prevention Not all head injuries can be prevented. But the following simple steps can help keep you and your child safe: Always use safety equipment during activities that could cause a head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats. Learn and follow bicycle safety recommendations. Do not drink and drive, and do not allow yourself to be driven by someone who you know or suspect has been drinking alcohol or is impaired in another way.

What is the Glasgow Coma Scale? The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. Basically, it is used to help gauge the severity of an acute brain injury. The test is simple, reliable, and correlates well with outcome following severe brain injury. The GCS is a reliable and objective way of recording the initial and subsequent level of consciousness in a person after a brain injury. It is used by trained staff at the site of an injury like a car crash or sports injury, for example, and in the emergency department and intensive care units. The GCS measures the following functions: Eye Opening (E) 4 3 2 1 = = = = spontaneous to voice to pain none

Verbal Response (V) 5 4 3 2 1 = = = = = normal conversation disoriented conversation words, but not coherent no words, only sounds none

Motor Response (M) 6 = normal 5 = localized to pain 4 = withdraws to pain 3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bend and held on the chest) 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards) 1 = none Clinicians use this scale to rate the best eye opening response, the best verbal response, and the best motor response an individual makes. The final GCS score or grade is the sum of these numbers. Using the Glasgow Coma Scale Every brain injury is different, but generally, brain injury is classified as: Severe: GCS 3-8 (You cannot score lower than a 3.) Moderate: GCS 9-12 Mild: GCS 13-15 Mild brain injuries can result in temporary or permanent neurological symptoms and a neuro-imaging tests such as CT scan or MRI may or may not show evidence of any damage. Moderate and severe brain injuries often result in long-term impairments in cognition (thinking skills), physical skills, and/or emotional/behavioral functioning. Limitations of the Glasgow Coma Scale Factors like drug use, alcohol intoxication, shock, or low blood oxygen can alter a patients level of consciousness. These factors could lead to an inaccurate score on the GCS. Children and the Glasgow Coma Scale The GCS is usually not used with younger children, especially those too young to have reliable language skills. The Pediatric Glasgow Coma Scale, or PGCS, a modification of the scale used on adults, is used instead. The PGCS still uses the three tests eye, verbal, and motor responses and the three values are considered separately as well as together. Here is the slightly altered grading scale for the PGCS:

Eye Opening (E) 4 3 2 1 = = = = spontaneous to voice to pain none

Verbal Response (V) 5 4 3 2 1 = = = = = smiles, oriented to sounds, follows objects, interacts cries but consolable, inappropriate interactions inconsistently inconsolable, moaning inconsolable, agitated none

Motor Response (M) 6 = moves spontaneously or purposefully 5 = withdraws from touch 4 = withdraws to pain 3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bend and held on the chest) 2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards) 1 = none Pediatric brain injuries are classified by severity using the same scoring levels as adults, i.e. 3-8 reflecting the most severe, 9-12 being a moderate injury and 13-15 indicating a mild TBI. As in adults, moderate and severe injuries often result in significant long-term impairments.

Neurological Examination What is a neurological examination? A neurological examination, also called a neuro exam, is an evaluation of a person's nervous system that can be performed in the doctor's office. It may be performed with instruments, such as lights and reflex hammers, and usually does not cause any pain to the patient. The nervous system consists of the brain, the spinal cord, and the nerves from these areas. There are many aspects of this examination, including an assessment of motor and sensory skills, balance and coordination, mental status (the patient's level of awareness and interaction with the environment), reflexes, and functioning of the nerves. The extent of the examination depends on many factors, including the initial problem that the patient is experiencing, the age of the patient, and the condition of the patient. Why is a neurological examination performed?

A complete and thorough evaluation of a person's nervous system is important if there is any reason to think there may be an underlying problem, or during a complete physical. Damage to the nervous system can cause problems in daily functioning. Early identification may help to identify the cause and decrease long-term complications. A complete neurological examination may be performed: During a routine physical Following any type of trauma To follow the progression of a disease If the person has any of the following complaints: Headaches Blurry vision Change in behavior Fatigue Change in balance or coordination Numbness or tingling in the arms or legs Decrease in movement of the arms or legs Injury to the head, neck, or back Fever Seizures Slurred speech Weakness Ttremor What is done during a neurological examination? During a neurological examination, the doctor will "test" the functioning of the nervous system. The nervous system is very complex and controls many parts of the body. The nervous system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that come from the spinal cord. The circulation to the brain, arising from the arteries in the neck, is also frequently examined. In infants and younger children, a neurological examination includes the measurement of the head circumference. The following is an overview of some of the areas that may be tested and evaluated during a neurological examination. Mental status Mental status (the patient's level of awareness and interaction with the environment) may be assessed by conversing with the patient and establishing his or her awareness of person, place, and time. The person will also be observed for clear speech and making sense while talking. This is usually done by the patient's doctor just by observing the patient during normal interactions. Motor function and balance This may be tested by having the patient push and pull against the doctor's hands with his/her arms and legs. Balance may be checked by assessing how the person stands and walks or having the patient stand with his/her eyes closed while being gently pushed to one side or the other. The patient's joints may also be checked simply by passive (performed by the doctor) and active (performed by the patient) movement. Sensory examination The patient's doctor may also perform a sensory test which tests his/her ability to feel. This may be done by using different instruments: dull needles, tuning forks, alcohol swabs,

or other objects. The doctor may touch the patient's legs, arms, or other parts of the body and have him/her identify the sensation (for example, hot/cold, sharp/dull). Newborn and infant reflexes There are different types of reflexes that may be tested. In newborns and infants, reflexes called infant reflexes (or primitive reflexes) are evaluated. Each of these reflexes disappears at a certain age as the infant grows. These reflexes include: Blinking - an infant will close his/her eyes in response to bright lights. Babinski reflex - as the infant's foot is stroked, the toes will extend upward. Crawling - if the infant is placed on his/her abdomen, he or she will make crawling motions. Moro's reflex (or startle reflex) - a quick change in the infant's position will cause the infant to throw the arms outward, open the hands, and throw back the head. Palmar and plantar grasp - the infant's fingers or toes will curl around a finger placed in the area. Reflexes in the older child and adult These are usually examined with the use of a reflex hammer. The reflex hammer is used at different points on the body to test numerous reflexes, which are noted by the movement that the hammer causes. Evaluation of the nerves of the brain There are 12 main nerves of the brain, called the cranial nerves. During a complete neurological examination, most of these nerves are evaluated to help determine the functioning of the brain: Cranial nerve I (olfactory nerve) This is the nerve of smell. The patient may be asked to identify different smells with his/her eyes closed. Cranial nerve II (optic nerve) This nerve carries vision to the brain. A visual test may be given and the patient's eye may be examined with a special light. Cranial nerve III (oculomotor) This nerve is responsible for pupil size and certain movements of the eye. The patient's doctor may examine the pupil (the black part of the eye) with a light and have the patient follow the light in various directions. Cranial nerve IV (trochlear nerve) This nerve also helps with the movement of the eyes. Cranial nerve V (trigeminal nerve) This nerve allows for many functions, including the ability to feel the face, inside the mouth, and move the muscles involved with chewing. The patient's physician may touch the face at different areas and watch the patient as he/she bites down. Cranial nerve VI (abducens nerve) This nerve helps with the movement of the eyes. The patient may be asked to follow a light or finger to move the eyes. Cranial nerve VII (facial nerve) This nerve is responsible for various functions, including the movement of the muscles

of the lower face and taste from the front of the tongue. The patient may be asked to identify different tastes (sweet, sour, bitter), asked to smile, move the cheeks, or show the teeth. Cranial nerve VIII (acoustic nerve) This nerve is the nerve of hearing. A hearing test may be performed on the patient. Cranial nerve IX (glossopharyngeal nerve) This nerve is involved with taste and swallowing. Once again, the patient may be asked to identify different tastes on the back of the tongue. The gag reflex may be tested. Cranial nerve X (vagus nerve) This nerve is mainly responsible for the ability to swallow, the gag reflex, some taste, and part of speech. The patient may be asked to swallow and a tongue blade may be used to elicit the gag response. Cranial nerve XI (accessory nerve) This nerve is involved in the movement of the shoulders and neck. The patient may be asked to turn his/her head from side to side against mild resistance, or to shrug the shoulders. Cranial nerve XII (hypoglossal nerve) The final cranial nerve is mainly responsible for movement of the tongue. The patient may be instructed to stick out his/her tongue and speak.