HEAD INJURY

HEAD INJURY
HEAD INJURY
HEAD INJURY
HEAD INJURY
 Head Injury

Any degree of traumatic brain injury ranging from

scalp laceration to LOC to focal neurological
deficits
Head Injury

Causes
• Motor vehicle accidents
• Falls
• Assaults
• Sports-related injuries
• Firearm-related injuries
 Head Injury

High potential for poor

outcome
Deaths occur at three points
in time after injury:
•Immediately after the injury
•Within 2 hours after injury
•3 weeks after injury
Head Injury

TYPES:
• Scalp laceration
• Skull Fractures
• Minor Head Trauma
Concussion and post-
concussion syndrome
• Major Head Trauma:
Cerebral contusion
Laceration
 Intracranial Perfusion

 Cranial volume fixed

 80% = Cerebrum, cerebellum & brainstem
 12% = Blood vessels & blood
 8% = CSF
 Increase in size of one component
diminishes size of another
 Inability to adjust = increased ICP
Head Injury

Scalp lacerations
• The most minor type of head trauma
• Scalp is highly vascular - profuse
bleeding
• Major complication is infection
 Head Injury

Skull fractures :
• Linear Skull Fracture
• Depressed Skull Fracture

• Basal Skull Fracture

• Compound Skull Fracture
• Compound elevated Skull
Fracture
• Growing Skull Fracture
Head Injury

• Skull fractures
Location of fracture alters the presentation of
the manifestations
• Facial paralysis
• Conjugate deviation of gaze
• Battle’s sign, Raccoon eyes
Basilar Skull Fracture

Battle’s sign Raccoon eyes

Investigations

• X-ray
• CT scan: standard modality
• MRI

• Bleeding from the ear or nose in cases of

suspected CSF leak

• CSF leak - analyzing the glucose level

 Management
Pre-hospital care:
• Patients with severe head injuries should be
assumed to have a cervical spine (C-spine) injury
and immobilized with cervical collar

• Minimize CSF leak

• Bed flat
• Never suction orally; never insert NG tube; caution
patient not to blow nose
• Place sterile gauze/cotton ball around area

Definitive Rx:
• Measures to reduce ICP
• Supportive management
• Surgery
 Head Injury

Major head trauma

• Includes cerebral contusions and lacerations
• Both injuries represent severe trauma to the
brain
 Head Injury

Major head trauma

Contusion
The bruising of brain tissue within a focal area
that maintains the integrity of the pia mater and
arachnoid layers associated with multiple micro-
hemorrhages, small vessel bleed into brain
tissue
Lacerations
Involve actual tearing of the brain tissue
Intracerebral hemorrhage is generally
associated with cerebral laceration
Head Injury

Cerebral Contusion Cerebral Laceration

 Intracranial Hemorrhage

• Extra- axial hemorrhage

Epidural hematoma
Subdural hematoma-
Acute
Chronic
Subarachnoid hemorrhage
• Intra-axial hemorrhage
• Intra-parenchymal
hemorrhage
• Intra-ventricular hemorrhage
 Intracranial Hemorrhage

•
•

•
 Epidural and Subdural Hematomas

Epidural Hematoma

Subdural Hematoma
 Epidural and Subdural Hematomas
Hematoma type Epidural Subdural

Location Between the skull and the dura Between the dura and
the arachnoid
Involved vessel Temperoparietal (most likely) - Middle Bridging veins
meningeal artery
Frontal - anterior ethmoidal artery
Occipital - transverse or sigmoid
sinuses
Vertex - superior sagittal sinus
Symptoms Lucid interval followed Gradually
by unconsciousness increasing headache and
confusion
CT appearance Biconvex lens- limited by suture lines Crescent shaped- crosses
suture lines
Subarachnoid Hemorrhage

Causes:
• Rupture of aneurism(MCC)
• Trauma (fracture at the base of the skull
leading to internal carotid aneurysm)
• Amyloid angiopathy
• Blood dyscrasias
• Vasculitis

Clinical Features:
• Explosive or thunderclap headache, ―worst
headache of my life‖,
• Nausea and vomiting, decreased LOC or
coma.
• Signs of meningeal irritation
Intracerebral Hemorrhage (ICH)

Intracranial hemorrhage is hemorrhage that occurs

within the brain tissue itself; an intra-axial
hemorrhage.

Two main types:

• Intraparencymal hemorrahge- ICH extending into
brain parenchyma; - HTNsive vasculopathy
• Intra-ventricular hemorrhage- ICH extending into
ventricles; –trauma
Causes:
Hypertensive vasculopathy(70-80%)
Ruptured AVM
Trauma
Blood dyscrasias
Intracerebral Hemorrhage (ICH)

Clinical presentation: Rapidly progressive severe

headache, building over several minutes, often
accompanied by focal neurological deficits, nausea and
vomiting, decreased level of consciousness.

S/S depend site of hemorrhage:

Basal ganglia/internal capsule - hemiparesis,
dysphasia
Cerebellum - ataxia, vertigo
Pons - cranial nerve deficits, coma
Cerebral cortex- hemiparesis, hemi-sensory loss,
dysphasia
Complications

• Neurological deficits or death

• Seizures
• Obstructive Hydrocephalus
• Spasticity
• Urinary complications
• Aspiration pneumonia

• Neuropathic pain
• Deep venous thrombosis
• Pulmonary emboli
• Cerebral herniation
 Diagnostic Studies

CT scan –

A GCS score less than 15 after blunt head

trauma warrants a patient with no intoxicating
consideration of an urgent CT scan.
 CT findings

Epidural Hematoma Subdural Hematoma

 CT findings

Subarachnoid hemorrhage Intracerebral hematoma

 Diagnostic Studies

• MRI – superior for demonstrating the size of an acute

subdural hematoma.
• Cerebral angiogram if hemorrhage is confirmed (not
necessary in case of classic hypertensive hemorrhage)
• Cervical spine X-ray
• EEG
• Lumbar Puncture
Management
1) Supportive Measures:

• Endotracheal intubation

• Cautiously lower blood pressure to a MAP less

than 130 mm Hg, but avoid excessive
hypotension.[10]
• Rapidly stabilize vital signs, and simultaneously
acquire emergent CT scan.
• Avoid hyperthermia.
• Facilitate transfer to the operating room or ICU.
Management

2) Decrease cerebral edema:

• Modest passive hyperventilation to reduce

PaCO2
• Mannitol, 0.5-1.0 gm/kg slow iv push
• Furosemide 5-20 mg iv
• Elevate head 20-30 degrees, avoid any neck
vein compression
• Sedate and paralyze if necessary with
morphine and vecuronium (struggling, coughing
etc will elevate intracranial pressure)
 Management

Surgical Decompression contd..

Types:

• Burr-hole
• Craniotomy- bone flap is temporarily removed
from the skull to access the brain
• Craniectomy – in which the skull flap is not
immediately replaced, allowing the brain to
swell, thus reducing intracranial pressure
• Cranioplasty - surgical repair of a defect or
deformity of a skull.
Assessment parameters for the patient with a head
injury include (A) eye opening and responsiveness,
(B) vital signs
Assessment parameters for the patient with a head injury:
(C, D) motor response reflected in hand strength or
response to painful stimulus.