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 mainly 5 more males within this group

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 haematomaIntra-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/ALERT Principles 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.

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, p