1. Assessment and initial management
Head Injury
Assessment and initial management

2. 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.

3. 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

4. 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.

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

6. 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

7. 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.

8. 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

9. Diffuse axonal injury CT

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

11. Cerebral contusion

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

13. Extradural haemorrhage

15. 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

16. Subdural haemorrhage

17. 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.

18. Subarachnoid haemorrhage

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

20. Intracerebral Haemorrhage

21. 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

22. Mild Head Injury
A patient with an initial GCS score of 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%)

23. 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

24. Exclusions
Clinically obvious penetrating injury
Non-traumatic injury

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

26. 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

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

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

29. Severe head injury classified as GCS 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.

30. 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

31. 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

32. 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

33. 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.

34. 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”.

35. 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.

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

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