Assessment and initial management Head Injury Assessment and initial management

Objectives Understand the difference between blunt and penetrating head trauma. Develop an understanding of types of blunt head trauma. Develop an understanding of the assessment and management of head injury.

Definitions Penetrating head trauma - external breach of the scalp and cranium. Blunt, traumatic head injury - caused by a direct blow or via deceleration (contra coup injury) - Classified as mild, moderate, severe - Peaks in early 20’s then again in elderly

Penetrating head injury External breach of scalp and cranium with direct injury. Can cause localized or generalized injury. Low velocity versus high velocity. Damage to surrounding structures. Complex management with balance between neuroprotection and excessive haemorrhage.

Types of blunt head injury Concussion Diffuse axonal injury Cerebral contusion Extradural haemorrhage Subdural haemorrhage Subarachnoid haemorrhage Intracerebral haemorrhage

Concussion Synonym for mild TBI Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. No structural damage on imaging studies

Westmead Post Traumatic Assessment What is your name? What is the name of this place? Why are you here? What month are we in? What year are we in? In what town/suburb are you in? How old are you? What is your date of birth? What time of day is it? (morning, afternoon, evening) Three pictures are presented for subsequent recall An incorrect response is indicative of injury requiring further investigation.

Diffuse axonal injury Caused by shearing mechanisms Leads to multiple small(diffuse) lesions throughout the brain and an elevated intracranial pressure. Can have a poor outcome in severe cases

Diffuse axonal injury CT

Cerebral contusion Commonly occur in acceleration/deceleration injuries (contra-coup) Coalescence may lead to an intracerebral haematoma.

Cerebral contusion

Extradural haemorrhage Result of direct trauma Usually in younger patients Usually associated with skull fractures May benefit from decompression Better prognosis than other bleeds

Extradural haemorrhage

Subdural haemorrhage More common in the elderly Result from stretching of subdural vessels with age and then tearing with injury Can be catastrophic particularly if on anticoagulants

Subdural haemorrhage

Subarachnoid haemorrhage Normally occur with severe trauma but also occur due to congential aneurysms In trauma due to disruption of the small vessels associated with pia mater.

Subarachnoid haemorrhage

Intracerebral haemorrhage Occurs mostly in patients on anticoagulants. Also seen in haemorrhagic stroke Tend to extend and have a poor prognosis

Intracerebral Haemorrhage

Consequences of increased ICP Decreasing GCS -> airway compromise, combative, further injury Increasing ICP -> coning Head injury associated coagulopathy Secondary cererebral injury - inflammatory resposnes - free radical injury - Secondary ischemia from vasospasm, focal microvascular occlusion, vascular injury

Mild Head Injury A patient with an initial GCS score of 14-15 on arrival at hospital following acute blunt head trauma with or without a definite history of loss of consciousness or post traumatic amnesia. Most commonly encountered head injury(80%)

Typical characteristics Direct blow to the head or acceleration / deceleration injury. Transient loss of consciousness or brief post traumatic amnesia. Transient abnormal alertness, behaviour or cognition. Rapid clinical improvement

Exclusions Clinically obvious penetrating injury Non-traumatic injury

Presentation Varies widely Headache Vague Dizziness Lethargy Vomiting Amnesia Transient loss of consciousness

Assessment Mild head injury patients should be assessed by a process of structured clinical assessment involving a combination of: initial clinical history and examination serial clinical observations

Serial clinical observation should include minimum hourly observations of : vital signs. pupillary reactions GCS (take note of confounders) alertness / behavior / cognition

Moderate to severe head injury Moderate head injury is classified by a GCS of 9-13 - 10% of presentations - significant risk of deterioration - close observation - prevent secondary injury: hypoxia/hypotension - need admission and CT

Severe head injury classified as GCS 3-8 - Urgent intervention to avoid secondary injury. - early intubation and neuroprotective measures. - ideal should be urgent retrieval team assessment and assistance. - transport to most suitable facility.

Head injury management ALL MANAGEMENT AIMED AT PREVENT SECONDARY BRAIN INJURY!! Observation and serial assessment Consider C-spine protection Reassurance and maintain control of patient Oxygen Maintain and protect airway Head elevation Early retrieval/transfer

Stabilization (fluids, drugs, hypertonic saline/mannitol) RSI (pre-oxygenation, maintain BP, avoid prolonged hypoxia) - drug choice (Ketamine vs Thio vs Propofol) Avoid hypercarbia and maintain oxygenation HYPOTENSION is the killer Maintenance and positioning

C collar Becoming increasingly controversial Applied without thought Can be potentially harmful and can remove focus from life threats such as airway No RCT ever performed on effectiveness of spinal immobilization Injury is done at time of accident, unlikely anything you will do will make matters worse

Collars are extremely uncomfortable and do not prevent movement Collars are extremely uncomfortable and do not prevent movement. May lead to patients being unco- operative. Study in 1998 between US (all collars) and Malaysia (no collars) concluded collars had little or no effect on neurological outcome in patients with blunt spinal injuries. Consider use of canadian c-spine rules.

Summary Wide variety of injuries All treatment is aimed at preventing secondary injury Consider PTA questions in cases of patients refusing transport Be careful of confounders Think critically about management/”protocols”.

Horse rider at bush races 40 y.o. male Thrown from horse at bush races No helmet Drinking during day prior to incident Initial LOC for a few minutes Disorientated progressing to minimal co-operation and agitation.

On our arrival agitated and poorly responsive to commands Haemodynamically stable PEARL Amnestic; disorientated

Sedated Intubated and ventilated IV fluids and maintenance of BP Transported to Sydney Diffuse axonal injury Prolonged stay in rehab