A&E(VMH) Head injury Dr. B.Padmashini Department of Accident, Emergency & Critical Care Medicine. Vinayaka Mission Kirupananda Variyar Medical College & Hospital. Salem,Tamil Nadu

A&E(VMH) Head Injury Number One Killer in Trauma 25% of all trauma deaths 50% of all deaths from MVC 200,000 people in the world live with the disability caused by these injuries

A&E(VMH) Road Traffic Crashes

A&E(VMH) Sports injuries

A&E(VMH) Assaults (Sickle injuries) Assaults (Sickle injuries)

A&E(VMH) Basic Anatomy Scalp Skull Meninges –Dura Mater –Arachnoid –Pia Mater Brain Tissue CSF and Blood

A&E(VMH) Skull

A&E(VMH) Dura- mater

A&E(VMH) Venous sinuses

A&E(VMH) Arachnoid mater

A&E(VMH) Pia- mater

A&E(VMH) CSF

A&E(VMH) Grey matter

A&E(VMH) White matter

A&E(VMH) Ventricles

A&E(VMH) Intracranial Volume 80% Brain Matter 10% Blood 10% CSF

A&E(VMH) The MONROE KELLIE doctrine Dictates that “the total volume of the intracranial contents MUST remain constant”

A&E(VMH) Normal state- ICP normal

A&E(VMH) Compensated state- ICP normal

A&E(VMH) Uncompensated state- ICP Elevated 75 ml

A&E(VMH) Volume-Pressure Curve

A&E(VMH) Intracranial Pressure The pressure of the brain contents within the skull is intracranial pressure (ICP) The pressure of the blood flowing through the brain is referred to as the cerebral perfusion pressure (CPP) The pressure of the blood in the body is the mean arterial pressure (MAP) CEREBRAL BLOOD FLOW Normal CBF – 50ml/100gm of brain/min “AUTOREGULATION”

A&E(VMH) ROLE OF INTRACRANIAL PRESSURE 10 mmHg -Normal > 20mmHg -Abnormal > 40mmHg -Severe  ICP  deteriorates brain function  poor outcome

A&E(VMH) Intracranial Pressure Cerebral Perfusion Pressure (CPP) can be determined by the following formula: CPP = MAP - ICP Normal CPP range is for autoregulation to work well!

A&E(VMH) SYMPTOMS & SIGNS OF INCREASED ICP Diminishing level of consciousness Headache, vomiting, seizures Cushing’s Triad –  bradycardia  hypertension  abnormal respiration Pupillary changes Papilledema

A&E(VMH) Primary Injury Mechanical irreversible damage - brain lacerations, hemorrhages, contusions, and tissue avulsions, Microscopy - primary injury causes permanent mechanical cellular disruption and microvascular injury. PATHOPHYSIOLOGY

A&E(VMH) Secondary Injury Neurologic outcome after head trauma - degree of secondary brain injury. Common Secondary systemic insults – Hypotension – SBP < 90 Hypoxia - Po2 less than 60 Anemia – reduces O2 Carrying capacity of the blood, to the injured brain tissue, Other causes - hypercarbia, hyperthermia, coagulopathy, and seizures.

A&E(VMH) morphology severity mechanism CLASSIFICATION

A&E(VMH) MECHANISM BLUNT INJURY  High Velocity  Low Velocity PENETRATING INJURY  Gunshot  Sharp instruments

A&E(VMH) Severity -GLASGOW COMA SCALE ASSESSMENT AREASSCORE Eye opening Best Motor Response Verbal Response Total Mild -GCS Moderate- GCS Severe - GCS 3 - 8

A&E(VMH)

MORPHOLOGY SCALP INJURY  Cephal Hematoma  Subgaleal Hematoma

A&E(VMH) SKULL FRACTURES Vault : linear/stellate depressed/non depressed open/closed

A&E(VMH) Basilar : with/with out CSF leak with/with out seventh-nerve palsy Battle sign Raccoon eyes CSF rhinorrhea

A&E(VMH) INTRACRANIAL LESIONS Focal : epidural hematoma subdural hematoma intracerebral hematoma

A&E(VMH) Epidural haematoma Collection of blood & clot b/n dura matter and bones of the skull Source Middle Meningeal Artery Dural Venous Sinuses C/F Brief loss of consciousness, headache,drowsiness,dizzy,nausea,vomitting Rapid clinical deterioration Talk & die

A&E(VMH)

EDH

A&E(VMH) Subdural hematomas Most frequently from tearing of a bridging vein between the cerebral cortex and a draining venous sinus. - acute - <24hrs - subacute – 24hrs-2wks - chronic - >2wks SDH Shape- Crescent

A&E(VMH) Intra Cerebral Heamatoma Formed within brain tissue & caused by shearing or tensile forces that mechanically stretch and tear deep small caliber arterioles Most common in temporal and frontal regions C/F depend on site involved

A&E(VMH) INTRACRANIAL LESIONS Diffuse : concussion multiple contusion hypoxic/ischemic injury

A&E(VMH) Concussion Temporary & brief interruption of neurological function after minor head injury Due to shearing / stretching of white matter fibres at the time of impact or temporary neuronal dysfunction C/o headache, confusion, amnesia CT/MRI cannot detect

A&E(VMH) DAI Shearing forces disrupt the axonal fibres in the white matter Shaken baby syndrome Blunt trauma Rapid rise in ICT. Prolonged or permanent.

A&E(VMH) APPROACH TO A PATIENT WITH HEAD INJURY History Initial Assessment  Primary Survey  Secondary Survey

A&E(VMH) PRIMARY SURVEY Airway maintenance with cervical spine protection

A&E(VMH) Breathing and ventilation : Intubation precautions Pre-medicate with Lidocaine, 1mg/kg IV 2 minutes prior to attempt Laryngoscopy produces an ICP Spike Intubation with Cervical inline stabilization

A&E(VMH) Circulation Maintain MAP >90mmhg- adequate Hematocrit >30% Cushing reflex

A&E(VMH) Isolated intracranial injuries do not cause hypotension LOOK FOR THE CAUSE OF HYPOTENSION

A&E(VMH) Disability Pupil size GCS Pupillary Changes Irregular shaped Equality? Constricted? Dilated? Vision Problems?

A&E(VMH) Assessment Findings Constricted? –narcotics? Sluggish/dilated? –mid brain ICP Unilateral dilation? –pressure on CNIII Fixed and Dilated? –herniation

A&E(VMH) SECONDARY SURVEY AMPLE history Examination of Head to toe Glasgow Coma Scale Detailed Neurological Examination

A&E(VMH) IMAGING STUDIES ONLY AFTER HEMODYNAMIC STABILIZATION

A&E(VMH) MANAGEMENT OF MILD HEAD INJURY(GCS13 -15) History General Examination Limited Neurologic Examination C-spine and other X-rays as indicated CT scan

A&E(VMH) CRITERIA FOR ADMISSION No CT scanner available Abnormal CT scan findings All penetrating head injuries Skull fractures CSF leak Deteriorating level of consciousness Moderate to severe headache Significant alcohol / drug intoxication Significant associated injuries

A&E(VMH) INDICATIONS FOR CT SCAN Skull fracture Deteriorating GCS Neurologic deficit Amnesia, headache Seizure

A&E(VMH) MANAGEMENT OF MODERATE HEAD INJURY(GCS 9-12) Initial Examination - Same as for mild head injury - CT scan brain – obtained in all cases - Admission for observation After Admission Frequent Neurologic Checks Improved Deteriorates (10%) Discharge Follow up Repeat CT scan Manage as per severe head injury protocol

A&E(VMH) MANAGEMENT OF SEVERE HEAD INJURY(3 - 8 ) Primary Survey and Resuscitation Secondary Survey and ‘AMPLE’ history Admit to facility – neurosurgical care Neurologic Re-evaluation –Eye opening –Motor response – Verbal response –Pupillary reaction

A&E(VMH) CT scan only after hemodynamic stabilization Medical therapy for raised ICP Immediate neurosurgeon opinion If needed surgical management

A&E(VMH) Head end elevation – 30 deg Intravenous fluids: Maintain normovolemia Hypotonic/glucose containing fluids should not be used Serum sodium levels monitored daily MEDICAL THERAPIES FOR HEAD INJURY

A&E(VMH) Mannitol g/kg Osmotic agent- dec ICP, maintains CBF,CPP and brain metabolism Dec ICP within 6 hrs. Expands volume, O2 carrying capacity. Diuretic effect- net intravascular volume is reduced.

A&E(VMH) Furosemide To reduce ICT in conjunction with mannitol Dose 0.3 to 0.5 mg/kg Never use in Hypovolemia

A&E(VMH) HYPERVENTILATION No role as prophylaxis in 24 hrs. Reducing PaCO2 cerebral vasoconstriction Maintain PaCo2 25 – 35 mmhg Last resort for reducing ICP TEMPORARY MEASURE ONLY.

A&E(VMH) Barbiturates Effective in reducing ICP – refactory to other measures Not used in presence of hypotension/hypovolemia

A&E(VMH) Anticonvulsants  Phenytoin- Loading dose - 18 – 20 mg/kg Maintenance dose mg q 8 hrly

A&E(VMH) Surgical management Scalp wounds cleaning & debridemant Elevation of depressed Fractures Craniotomy & evacuation of Haematoma Cranial decompression for reduction of ICT

A&E(VMH) Burr hole evacuation

A&E(VMH) SUMMARY Endotracheal intubation if GCS < 8 Moderate hyperventilation Treat shock aggressively Resuscitate with normal saline or Ringer’sLactate solutions. Goal is to achieve a euvolemic state contd..

A&E(VMH) SUMMARY Frequent neurological assessment Exclude cervical spine injuries Transfer all moderate to severe head injured patients if neuro surgeon is not available at your facility

A&E(VMH)