Adult Head Injury

Rajiv Sighamoney

Objectives

To have a knowledge and understanding of types of Head Injury (HI)

Epidemiology of HI

• 1,000,000 hospitalised /year as of result • Males 2-3 x more likely to suffer• Age group 15-29 mainly• 5 more males within this group

www.headway.org.uk

Cerebro-spinal fluid

Cerebral arterial blood flow

Types- Severity

• Minor – 150,000

• Moderate– Unconsciousness for 0-6hrs– Some have physical & psychological problems after 5 yrs– 10,000

• Severe HI– Unconscious 6+hrs– Of these only approx 15% return to work within 5yrs– 11,600

Types-open or closed

• Open– Penetrating– Low velocity (stab wound) – High velocity (Gun shot/Nail gun) – Resultant local damage to the brain and along the

tract

Open Head Injury – Skull Penetration

Types-open or closed

• Closed– Focal

• Direct blow to the head or from a fall • Assault 10%• Domestic incidents 20-30%• Sport 10-15%• Cycling - °helmet 20%

– Diffuse• RTA 40-50%• Acceleration-deceleration forces result in

shearing and contusion injury • Diffuse axonal injury

Types- Pathology

• Concussion– Usually reversible traumatic paralysis of

nervous function

• Contusion– Bruising or crushing without interruption of

physical continuity

• Diffuse axonal injury– Acceleration-deceleration forces result in

shearing and contusion injury

Coup and Contra-coup mechanism

Actual brain injury• Bruising

– Small blood vessels ruptured– Haematoma

• Tearing– May not be observed on CT/MRI

• Swelling– As a result of the normal response to injury – i.e. exudate, increased blood flow

Monro-Kellie hypothesis• The intact cranium & vertebral canal with

the relatively inelastic dura form rigid container

• ↑ in intracranial contents, viz, brain, blood or CSF will ↑ ICP

• If one of these three elements ↑ in volume it must be at the expense of the other two

Example of internal injury

Epidural haematoma Intra-cerebral haematoma

Factors increasing ICP

• Hypoxaemia/hypercapnia

• Worsening oedema, bleeding

• Pyrexia

• Anxiety, pain

• Positioning - tip & turn, head movements

• Cough

• Suctioning

Associated injuries• In polytrauma there may be

– chest wall injury and lung damage– multiple fractures– abdominal & pelvic injuries

• Major blood loss• Loss of consciousness resulting in

airway compromise

↓CRITICALLY ILL PATIENT

Non-traumatic head injuries

• CVA

• Sub-arachnoid haemorrhage

• Aneurysm

• Tumours

• Cerebral oedema

• Encephalopathy with electrolyte imbalance

Aims of medical management

• Treat 1° brain injury – Stop bleeding– Remove clots– Maintain adequate CBF Metabolic demands– Promote cerebral draining– Control ICP

• To prevent further 2° brain damage

Treatment

• Decompress–Craniotomy–Burr holes–Bone flap removal

• Dehydrate

• Drugs

• CSF drainage

GM AIM/ALERTPrinciples of assessment

• A (Airway) - Maintain airway

• B (Breathing) - Ventilate & Sedate (GCS<8)

• C (Circulation) - Monitor CVS

• D (Disability) - Neurological assessment

• E (Extremity) - Control fitting

Bibliography• Fewings, J. (1999) ‘Management of the

Acute Head Injury’, Royal Hallamshire Hospital, Sheffield, (Unpublished presentation).

• GM AIM (2003) ‘Greater Manchester Acute Illness Management’, Course Booklet. Greater Manchester Critical Care Skills Institute NHS.

• http://images.google.co.uk• http://www.headway.org.uk

Further reading• Adams, A., et al (1998). ‘Chapter 6 The

Intensive Care Unit’, In: M. Smith, & V. Ball, (1998), Cardiovascular / Respiratory Physiotherapy. London: Mosby, pp 73 – 117.

• Enright, S., (1992). ‘Cardiorespiratory effects of chest physiotherapy’, Intensive Care Britain, 1992, p118-123.