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. –Temporary dysfunction which resolves after a variable period –Amnesia is common

Contusion & Laceration Small areas of hemorrhages Usually produce neurological deficits that persist for longer than 24 hours Diffuse axonal head injury As a result of mechanical shearing following deceleration, causing disruption and tearing of axons

The Secondary pathology: Intracranial : –Brain swelling, oedema. –Necrosis. Ischemia. –Hematoma. –Metabolic or endocrine disturbances. –Coning. –Coup & Counter-coup. –Infection –Epilepsy

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

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

Skull base fracture Diagnosed on clinical bases. They often result in CSF leak. Rhinorrhoea Anosmia C-C fistula Periorbital hematoma CSF otorrhoea Battle`s sign

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.) 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 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 BrainBlood CSFMass Bone

Reduce edema Promote venous return Reduce cerebral metabolic rate Reduce activity associated with elevated ICP

Management on head injuries Minor head injury

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

Indications for admission to hospital: Loss of consciousness. Persistent drowsiness. Focal neurological deficit. Skull fracture. Persisting nausea & vomiting Elderly & infant. W.

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

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.

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 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.