1. Head Injury Dr.saad farhan al masoudi

2. Is the most common cause of mortality and morbidity. Commonly affect healthy children and active young adults. Is a major public health problem. Is largely preventable. * Causes : RTA 50% FFH Assault Sports Industrial accident *prevention : Is the most effective means of improving survival rates. Little can be done as a treatment, improving safety devices in cars. safety laws : seat belts, helmets, …….est public education. *

3. Classification of Head injury Classification of Head injury 1. skull fracture with or without brain injury  vault fracture  base fracture 2. Focal brain injury which includes a.Brain contusion which define as abruises of neural parenchyma, always traumatic, wedge in shape, involve cortex surface associate with intact pial – glial membrane and these contusion subdivided to Coup ------ below site of impaction Coup ------ below site of impaction Contre coup ------ remote from site of impaed Contre coup ------ remote from site of impaed Intermediate ------ within brain parenchyma between site of impaction and opposite side of brain. Intermediate ------ within brain parenchyma between site of impaction and opposite side of brain. b. Hemorrhage / hematoma epidural epidural subdural subdural Intra cerebral Intra cerebral petechial petechial

7. 3.Diffuse brain injury a.concussion :- a transient reversible neurological dysfunction due to trauma not sufficient to cause structural damage to bruin parenchyma. b.diffuse axonal injury : structural damage to brain leading to prolong coma not cansed by mass effect, its severity depend on  duration of acceleration  magnitude of injury  rate of acceleration  direction of acceleration.

8. Mechanisms of Head trauma A. Contact injury : slow, focal brain injury this require that head strikes an object or is struck, regard less of whether the blow causes the head to move after ward. and include. 1. Local contact injury (effects ) examples,  linear skull fracture  depressed skull fracture  s.t. fracture base of skull  epidural hematoma  coup contusion 2. remote contact injury ( effects) :example 2. remote contact injury ( effects) :example vault fraeture vault fraeture fracture base of skull fracture base of skull contre coup contusion contre coup contusion Intermediate coup contusion Intermediate coup contusion Intracerebral hemorrhage Intracerebral hemorrhage

9. B.Head motion ( inertial ) injury : inertial injury are often called head motion injury or acceleration injuries because the result from violent head motion, regardless of whether the head moves because of a direct blow or not. inertial injury are often called head motion injury or acceleration injuries because the result from violent head motion, regardless of whether the head moves because of a direct blow or not. Inertial loading of head cause rapid movement of the head that resultant injury is due only to the manner in which the head moves. Inertial loading of head cause rapid movement of the head that resultant injury is due only to the manner in which the head moves. Head motion injuries termed acceleration injuries and these acceleration classified to Head motion injuries termed acceleration injuries and these acceleration classified to  transilation acceleration  Rotational acceleration  Angular acceleration(both transition) and rotation type, combine to gather )

10. Head motion injuries classified to : Head motion injuries classified to : 1.skull – brain relative motion subdural hemtomasubdural hemtoma contra coup contusioncontra coup contusion intermediate coup contusionintermediate coup contusion 2.Brain Deformation  Concussion syndrome  Diffuse axonal injury  Intracerebral hemorrhage  Tissue tear hemorrhage

11. pathophysiology of traumatic brain injury 1. Ischemia which caused by ↑ ICP ↑ ICP Local destructions by space occupying lesion.Local destructions by space occupying lesion. Severe vasoconstriction caused by release of K+ from ICC to ECC.Severe vasoconstriction caused by release of K+ from ICC to ECC. 2. Hypoxia due to Respiratory dysfunction Respiratory dysfunction Inadequate ventilation Inadequate ventilation Problems in O2 delivery Problems in O2 delivery 3. Acidosis : which a consequence of ischemia and hypoxic leading to lactic acid acidosis that affect protein synthesis and function → cell membrane neuronal damage. 4. free radicle formation : ( H2O2 ) which occur from reperfusion after trauma → neural damage 5. ↑ neurotransmitter → release secondary to ischemia like glutamate → neurotoxicity.

12. Systemic manifestation of traumatic brain injury 1. Abnormality of water and electrolyte homeostasis *Hyper natremia diabetes insipidns diabetes insipidns poor fluid intake. poor fluid intake. *hypo natremia *hypo natremia SIADH with ↑ blood volume SIADH with ↑ blood volume Cerebral salt wasting syndrome same as SIADH but with decrease in blood volume Cerebral salt wasting syndrome same as SIADH but with decrease in blood volume 2. hormonal abnormalities ( hypo and hyper secretion of anterior pituitary hormones ), increase catacholamine production. 3. Metabolic change, ( hyper metabolic state, depressed cellular immunity 4. cardio pulmonary malfunction cardiac subendocardial hemorrhage cardiac subendocardial hemorrhage  cardiac arrhythmia  heart failure pulmonary - neurogenic pulmonary edema ( few minute ) delayed pulmonary - neurogenic pulmonary edema ( few minute ) delayed pulmonary dysfunction 24 – 48 hr pulmonary dysfunction 24 – 48 hr

13. pathology of closed head injury pathology of closed head injury 1. soft tissue injuries of head and neck periorbital ecchymoses ( Raccoon eye ) periorbital ecchymoses ( Raccoon eye ) postauricular ecchymoses ( battle's sign ) postauricular ecchymoses ( battle's sign ) scalp ( abrasion, laceration, contusions ) scalp ( abrasion, laceration, contusions ) facial injury facial injury peripheral cranial nerve peripheral cranial nerve retinal hemorrhage. retinal hemorrhage.

16. 2. skull fracture : linear #: most common type seen in severe head injury cause by out bending of bone at a distance from impact side as a result of general deformation of skull. linear #: most common type seen in severe head injury cause by out bending of bone at a distance from impact side as a result of general deformation of skull. depressed # : can be define when the outer table of depressed segment of bone below the inner table of the non – depressed segment. depressed # : can be define when the outer table of depressed segment of bone below the inner table of the non – depressed segment. comminuted # : multiple linear #. comminuted # : multiple linear #. diastatic # : are linear fractures along sutures line resulting in separation of cranial sutures. diastatic # : are linear fractures along sutures line resulting in separation of cranial sutures.

23. 3. Brain injuries : A. primary brain injuries include. A. primary brain injuries include. 1. Focal injuries : 1. Focal injuries : *Hematoma which are *Hematoma which are - intracerebral H. - intracerebral H. -extradural H. -extradural H. -subdural H. -subdural H. -subarachoid H.( most common ) -subarachoid H.( most common ) *Contusion / lacerations of. *Contusion / lacerations of. - brain tissue - brain tissue - brain stem - brain stem - cranial nerve - cranial nerve - blood vessels - blood vessels - pituitary gland and - pituitary gland and -hypothalamus. -hypothalamus. 2. Diffuse injuries : 2. Diffuse injuries : -Concussion -Concussion -Diffuse axonal injuries. -Diffuse axonal injuries.

28. B. secondary brain injuries due to : B. secondary brain injuries due to : 1. Ischemia of brain tissue neural tissues caused by 1. Ischemia of brain tissue neural tissues caused by  ↑ Icp and herniation  Mass effect  K + extracellular release and vasoconstrictor 2. hypoxia dne to : 2. hypoxia dne to :  Hypotension  Hypoventilation  Respiration dysfunction  Inadequate O2 deliver to tissues.

29. Evaluation of patient with head trauma Evaluation of patient with head trauma A. General evaluation : which include A. General evaluation : which include 1. head and neck, site of trauma 1. head and neck, site of trauma 2. other part of body like chest, abdomen, extremities. 2. other part of body like chest, abdomen, extremities. 3. vital signs, BP, PR, RR 3. vital signs, BP, PR, RR 4. reason behind head trauma. 4. reason behind head trauma. B. neurological evaluation : which include B. neurological evaluation : which include 1. Glasgow coma scale ( GCS ) for state and level of consciousness. 1. Glasgow coma scale ( GCS ) for state and level of consciousness. 2. pupils and cranial nerve examinations 2. pupils and cranial nerve examinations Pupillary light reflex, dolls eye( oculocephalic reflex ), swallowing Pupillary light reflex, dolls eye( oculocephalic reflex ), swallowing and vocal cord function. and vocal cord function. 3. motor responses : movement type, weakness, posture whether 3. motor responses : movement type, weakness, posture whether flexor or extensor. flexor or extensor. 4. sensory responses : painful stimuli commonly include nail bed 4. sensory responses : painful stimuli commonly include nail bed pressure or nipple pinching lead to patient arousal. pressure or nipple pinching lead to patient arousal.

30. 5. Reflexes : 5. Reflexes :  Brain stem reflexes  Cranial nerve reflexes  Muscle stretch reflexes 6. Respiration : 6. Respiration :  Cheyne – stokes breathing → cortical lesion  Uniform hyperventilation → pontine lesion  Irregular, ataxic breathing → medullar lesion 7. Brain death examination : 7. Brain death examination :  Apnea test  Brain stem reflexes  EEG ( electroencephalography )  Angiography 8. Glasgow out come scale 8. Glasgow out come scale  5 → good recovery  4 → moderate disability, independent  3 → severe disability, conscious, dependent  2 → persistent vegetative state  1 → Death

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