CROSS-SECTION

HEAD INJURY DEFINITION

Any injury that
results in trauma to
the SCALP, SKULL
or BRAIN.

TRAUMATIC
BRAIN
INJURYand HEAD
INJURYare often
used

HEAD INJURY - TYPES

OPEN HEAD INJURY:
There is penetration to the skull.

CLOSED HEAD INJURY

There is NO penetration to the
skull.

COUP-CONTRECOUP
INJURIES
Damage may occur
directly under the
site of impact
(COUP), or it may
occur on the side
opposite the
impact
(CONTRECOUP).

HEAD INJURY MECHANISMS

PRIMARY INTRACRANIAL
INJURY

It is the initial
neuronal damage that
occurs IMMEDIATELY
as result of trauma.

SECONDARY INTRACRANIAL
INJURY

Secondary injuries are

the result of the
neurophysiological
and anatomic
changes, which occur
from MINUTES to
DAYS after the
original trauma.

HEAD INJURY MECHANISMS

PRIMARY INTRACRANIAL
INJURY

Cerebral Laceration
Cerebral Contusion
Epidural Hematoma
Subdural Hematoma
Subarachnoid
Hematoma
Intracerebral
Hematoma
Diffuse Axonal Injury

SECONDARY INTRACRANIAL
INJURY

Edema

Impaired Metabolism

Altered Cerebral Blood

Flow

Free Radical Formation

Excitotoxicity

SCALP INJURIES
LACERATIONS

SUBGALEAL
HEMATOMA

SKULL INJURIES
CLOSED FRACTURES

A closed fracture has a

significant chance of
associated intracranial
haematoma.

OPEN FRACTURES
Open fractures have
potential for serious
infection.
Any foreign matter
impaled in the skull should
be left in place for removal
by the neurosurgeons.
Cover it lightly with a
sterile dressing that has
been moistened with a
sterile saline.

SKULL INJURIES
CT SCAN

OT

SKULL INJURIES
DEPRESSED FRACTURES/COMPOUND
DEPRESSED FRACTURES

NON-DEPRESSED LINEAL
FRACTURES

SKULL INJURIES - BASILAR

SKULL FRACTURE

SKULL INJURIES - BASILAR

SKULL FRACTURE
RACCOON EYE

SKULL INJURIES - BASILAR

SKULL FRACTURE
BATTLES SIGN

SKULL INJURIES - BASILAR

SKULL FRACTURE
BLEEDING FROM THE EAR
CANAL

CSF LEAKAGE FROM THE EAR

OR NOSE

BRAIN INJURIES
DIFFUSE

Concussion
Diffuse Axonal Injury

FOCAL
Contusion
Brain Lacerations
Epidural haematoma
Subdural haematoma
Subarachnoid
haemorrhage
Parenchymal
haematoma

HEAD INJURY (DIFFUSE) CONCUSSION

Brain injury that
does not result in
any evidence of
structural alteration.
Return of
consciousness
moments or
minutes after
impact.

There may be brief

confusion,
disorientation,
headache,
dizziness, amnesia.
CT scan is normal.

HEAD INJURY (DIFFUSE) DIFFUSE AXONAL INJURY

BRAIN CONTUSION

EPIDURAL HEMATOMA
SCHEMATIC

CT SCAN

SUBDURAL HEMATOMA
SCHEMATIC

CT SCAN

SUBARACHNOID
HEMATOMA
SCHEMATIC

CT SCAN

INTRACEREBRAL
HEMATOMA
SCHEMATIC

CT SCAN

HEMATOMAS

CEREBRAL EDEMA
NORMAL CT SCAN

CEREBRAL EDEMA

SIGNS
CUSHING REFLEX

A sign of ICP
(INTRACRANIAL
PRESSURE)

SIGNS
DILATED PUPIL
A UNILATERAL ,
FIXED DILATED PUPIL
indicates neurologic
deterioration may be
secondary to hypoxia,
hypovolaemia or
hypoglycaemia, due to
ICP, and compression
of the 3rd Cranial Nerve
(OCULOMOTOR
NERVE).

SIGNS

SIGNS
DECORTICATE
POSTURING
Arms Flexed
Arms bent inward on
the chest
Hands clenched into
fists
Legs Extended
Feet turned Inward
Score of 3 in the Motor
section of the Glasgow
Coma Scale

SIGNS
DECEREBRATE
POSTURING
Head is arched back
Arms Extended by the
sides
Legs Extended
Patient is rigid with
the teeth clenched.
Score of 2 in the Motor
section of the Glasgow
Coma Scale

SYMPTOMS
Confusion/Irritibility
Drowsiness
Dizziness
Nausea & Vomiting
Amnesia

Speech/Swallowing
Difficulty
CSF Leakage
Ear Bleeding
Numbness/Paralysis

Coma

SYMPTOMS

SYMPTOMS

DIAGNOSIS

DIAGNOSIS - HISTORY

DIAGNOSIS - PHYSICAL
EXAMINATION
ABCDE
A = AIRWAY
B = BREATHING
C = CIRCULATION
D = DISABILITY
E = EXPOSURE

GLASGOW COMA
SCALE (GCS)
SYSTEMIC
EXAMINATION

GLASGOW COMA SCALE

MINIMUM=3/15 MAXIMUM=15/15
INTUBATION <8/15

GLASGOW COMA SCALE

(GCS)
SEVERITY

SCORE

GLASGOW COMA SCALE

(GCS)
SEVERITY

LOSS OF
CONSCIOUSNESS

DIAGNOSIS - HEAD AND

NEUROLOGIC EXAM
HEAD EXAM
Hematoma
Contusion
Fracture e.g. Basilar
Skull Fracture
Laceration

NEUROLOGIC EXAM
Cranial Nerves
Muscle Tone
Muscle Power
Sensations
Walking Gait

DIAGNOSIS - OTHERS
TRANSCRANIAL
DOPPLER

TREATMENT

TREATMENT - ACUTE
STAGE
CERVICAL
IMMOBILIZATION

Philadelphia Collar

TREATMENT - ACUTE STAGE

(AIRWAY)
ENDOTRACHEAL
INTUBATION

SIGNS OF OXYGEN

If intubation is
impossible: Laryngeal
Mask or
Cricothyrotomy are
indicated.

Respiratory rate < 10or

>40 bpm.
S02 <90% breathing
oxygen or <85% breathing
air

Hypercarbia that implies

pH<7.2
Hypoxia Pa02<50 mm Hg

TREATMENT - ACUTE STAGE

(AIRWAY)
LARYNGEAL MASK

TREATMENT - ACUTE STAGE

(AIRWAY)
CRICOTHYROTOMY

TREATMENT - ACUTE STAGE

(AIRWAY)
ENDOTRACHEAL
INTUBATION

MECHANICAL VENTILATION
STANDARD PARAMETERS

Tidal Volume: 8-10

ml/kg
Rapid sequence
intubation is
performed, using
sedative agents and
muscle relaxants.

Rate:12-15 bpm
Pressure: 15-20 cm
H20
Fi02: 1

TREATMENT - ACUTE STAGE

(BREATHING)

Start high-flow oxygen

administration (10-12
l/min)

TREATMENT - ACUTE STAGE

(CIRCULATION)
Establish IV access
with two largebore(14- or16
gauge) IV cannulas.
IV infusion of Normal
Saline (NS).
IV Norepinephrine

AVOID giving 5%
Dextrose unless
hypoglycaemia is present.

Dextrose cerebral
oedema

If BP is normal AVOID
giving excessive volumes
of fluids that may
cerebral oedema.

TREATMENT - ACUTE STAGE

(DISABILITY)
TREATMENT FOR ICP

IV Mannitol (Osmotic
Diuretic)
IV Furosemide
Hyperventilation

TREATMENT - ACUTE STAGE

(DISABILITY)
TREATMENT FOR ICP

If there are no
counter-indications
(hypovolaemia, spine
injury) place the
patient in
ReverseTrendelenburg
position

REVERSE-TRENDELENBURG

TREATMENT - ACUTE STAGE

(DISABILITY)

If significant agitation and after

excluding hypoxia, hypovolaemia or
pain, as the cause of agitation: IV
Midazolam

TREATMENT - ACUTE STAGE

(EXPOSURE)
AVOID Body
Temperature

Pain medication: IV
Fentanyl
Anti-Emetics

Body Temperature:
Cooling measures
and
IV Paracetamol

Post-Traumatic
Seizures: IV
Diazepam

TREATMENT - ACUTE STAGE

(PARAMETERS)
MONITOR

BLOOD SAMPLES

Blood Pressure
Heart Rate
Respiratory Rate
S02, Etc02

ECG

Serum Electrolytes
Arterial Blood Gas
Hyper/Hypoglycaemia

TREATMENT - ACUTE STAGE

(CATHETERIZATION)
NASOGASTRIC TUBE
Place a Nasogastric tube
(NG Tube) to decompress
the stomach and reduce
the risk of vomiting as
aspiration.

AVOID NG Tube for

patients with facial
injuries. The tube could
enter the brain through a
bony fracture.

TREATMENT - ACUTE STAGE

(CATHETERIZATION)
URINARY CATHETER
Insert an indwelling
urinary catheter for
hourly urine output
monitoring.
AVOID insertion if
injury is suspected to
the urethra.

TREATMENT - ACUTE STAGE

(SURGERY)
DECOMPRESSIVE CRANIOTOMY

TREATMENT - CHRONIC
STAGE
REHABILITATION

COMPLICATIONS
Personality Changes

LONG-TERM EFFECTS

Hypopituitarism e.g. DI
Post-Traumatic Seizures

Parkinsons

Infections e.g. Meningitis

Alzheimers Dementia
Vasospasm, Aneurysm
Coma, Brain Death

PREVENTION