Head injuries

• A head injury is any trauma that leads to injury of the scalp, skull, or brain. These injuries can range from a minor bump on the skull to a devastating brain injury.

• Head injury can be classified as either closed or penetrating.

• In a closed head injury, the head sustains a blunt force by striking against an object

• In a penetrating head injury, an object breaks through the skull and enters the brain. (This object is usually moving at a high speed like a windshield or another part of a motor vehicle.)

• Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life.

• In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.

Pathophysiology• Direct trauma.• Cerebral contusion.• Intracerebral shearing.• Cerebral edema.• I.C.H• Hydrocephalus

Traumatic Head Injury

Cerebral Edema• Cellular response to injury

– Primary injury

– Secondary injury• Hypoxic-ischemic injury

– Injured neurons have increased metabolic needs– Concurrent hypotension and hypoxemia– Inflammatory response

The main factors which determine the severity of cerebral injury are:

• Distortion of the brain.• Mobility of brain in relation to skull

and meninges.• Configuration of interior of skull.• Deceleration and acceleration.• The pre-existing state of brain

(elderly).

Brain injury:– Concussion.

Contusion

Laceration

The Secondary pathology:• Intracranial :

– Brain swelling.– Necrosis. Ischemia.– Hematoma.– Vascular changes.– Coning.– Coup & Counter-coup.

• Extracranial :– Resp. failure, increase CO2.– Systemic B/P – Fluid, isotonic.– Temperature

• For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours.

• The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness

• If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.

• Signs of deterioration:– Becomes unusually drowsy– Develops a severe headache or stiff neck– Vomits more than once– Loses consciousness (even if brief)– Behaves abnormally

Skull fractures• Simple fracture.• Comminuted linear fracture of the vault.• Skull base linear fracture.• Depressed fracture. by: -falling objects. -Assault with a heavy blunt tool. -Missile injury. -R.T.A

• Compound depressed fracture:– Antibiotics.– Anti tetanus prophylaxis.– Surgery. Urgent.

• Closed depressed fracture

Closed depressed fracture Indication of surgery:

• Dural tear• Brain compression...

(Dural venous sinuses.)

• Compound.• Cosmetic.

Missile injuries:• Scalp injury.• Depressed skull fracture.• I.C.H.• Brain injury.

Management of Traumatic Head Injury

• Maximize oxygenation and ventilation

• Support circulation / maximize cerebral perfusion

pressure

CPP=MSP-ICP

• Decrease intracranial pressure

• Decrease cerebral metabolic rate

Monitoring

• Serial neurologic examinations

• Circulation / Respiration

• Intracranial Pressure• Radiologic Studies • Laboratory Studies

Circulatory Support: Maintain Cerebral Perfusion Pressure

0

1

2

3

4

5

6

Outcome

GoodModerateSevereVegetativeDead

Number of Hypotensive Episodes

Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

Lowering ICP

• Evacuate hematoma• Drain CSF

– Intraventricular catheters use is limited by degree of edema and ventricular effacement

• Craniotomy– Permanence, risk of infection, questionable

benefit

Brain Blood

CSF MassBone

• Reduce edema• Promote venous return• Reduce cerebral metabolic rate• Reduce activity associated with

elevated ICP

Management on head injuries• Minor head injury

Indications for admission to hospital:

• Loss of consciousness.• Persistent drowsiness.• Focal neurological deficit.• Skull fracture.• Persisting nausea & vomiting• Elderly & infant.• W.

Management

• Observation.• Bed elevated 20.• Mild fluid restriction.

Severe head injury• It depends on the patient’s neurological

state and the intracranial pathology resulting from the trauma.

• Clinical assessment and CT scan• Evacuation of any hematomas

• If there is no surgical lesion, or following the operation:

– Observation and GCS chart– Decrease intracranial brain swelling

• Airway management• Elevation of the head of the bed 20º• Fluid and electrolyte balance• Blood replacement with colloid or blood and

not crystalloid• No steroids

– Management of conditions resulted from head injury

• Severe hyponatraemia due to excessive fluid intake or inappropriate excessive secretion of ADH

• Hypernatraemia due to inadequate fluid intake.

• Diabetes insipidus

• Temperature control, pyrexia due to hypothalamic damage or traumatic SAH or infection or from CSF leak and meningitis

– Nutrition:• During the initial 2-3 days the fluid therapy

will include 1.5-2 liters of 5% dextrose• After 3-4 days by nasogastric feeding

– Routine care of the unconscious patient, bowel, bladder and skin.

– Intracranial monitoring in more severe cases.