Presentation made at GMCTH, Pokhara during the period of internship!

1. Head Injuries
Dr Sajal Twanabasu
Intern
GMCTH

2. Definition
 Any injury that results in the trauma to the scalp, skull or
brain.
 Traumatic brain injury (TBI) encompasses a broad range of
pathologic injuries to the brain of varying clinical severity
that result from head trauma.
 Head injury and traumatic brain injury are often used
interchangeably

3. Etiology
 Motor Vehicle Crashes- 44%
 Falls - 26%
 Other/Unknown - 13%
 Non-Firearm Assaults - 9%
 Firearms - 8%

4. Pathophysiology
 On the basis of mechanism of production, head injury can be
classified as:
 Impact injuries: It results from an object striking the head or
the head striking an object.
 It includes:
Scalp injuries
Skull fracture
Cerebral contusion and laceration
Epidural haematoma

5.  Acceleration and deceleration injuries: It results essentially
as a result of differential movement between skull and
cranial content.
 It includes:
Diffuse axonal injury
Sub-dural hematoma

6. 666
Coup injury
Contracoup injury
Coup injury:
 It occurs at the site of the impact to the head and are
produced by compression of brain due to inward movement
of the bone
Countre-coup:
 Injury occurs directly opposite to
the point of impact and are most
common in frontal and temporal
lobe.
 Produced by the head in motion
impacting on a stationary object

7. Consequences of head injury
Injury to the scalp:
 There can be scalp contusion, abrasion and/or lacerations
 Tremendous vascularity of the scalp can cause profuse
bleeding
 Osteomyelitis may develop after closed injury following
infections of sub-periosteal blood clot referred as Pott’s Puffy
tumour

8. Skull Fracture
Simple linear fracture:
 It is the break in the bone that transverses the full thickness
of the skull from the outer to inner table
 No clinical significance
 Fracture that transverses a suture line or involves a venous
sinus groove or vascular groove should be dealt cautiously

9. Depressed Skull Fracture
 Results from blunt trauma
 Inner table extensively affected than the outer table
 High risk of increased pressure on the brain or hemorrhage
to the brain that crushes the delicate tissue

10.  Compound depressed fracture is in contact with the outside
environment increasing the risk of contamination and infection
 Complex depressed fracture tears the duramater increasing the
risk of cortical damage and epilepsy

11. Base of skull fracture
Anterior cranial fossa fracture:
 It may lead to subconjunctival haematoma, extending to
posterior limit of sclera, epistaxis, CSF rhinorrhea
Middle cranial fossa fracture:
 It involving the petrous temporal bone presents with CSF
otorrhoea, haemotympanium, ossicular disruption, Battle
sign, 7th and 8th cranial nerve palsy.

13. Brain injury
Primary brain injury:
 Injury caused at the time of impact
 Irreversible
Secondary brain injury
 Subsequent or progressive brain damage arising from events
developing as a result of primary brain injury

14. Primary braininjury Secondarybraininjury
Concussion Intracranial haematoma
Cortical laceration/contusion Cerebral oedema
Diffuse axonal injury Ischaemia
Bone fragmentation Infection
Metabolic or endocrine
disturbances

15. Diffuse Axonal Injury
 Results from mechanical shearing at grey- white interface
due to severe acceleration and deceleration force
 No obvious structural damage
 Severity may range from mild damage with confusion to
coma and even death
 Major cause of unconsciousness and persistent vegetative
state after head trauma

17. Cerebral Concussion
 It is the condition of temporary dysfunction of brain without
any structural damage following head injury
 It is manifested as:
Transient loss of consciousness
Transient loss of memory
Autonomic dysfunction like bradycardia, hypotension and
sweating

18. Cerebral Contusion
 It is more severe degree of brain injury manifested by areas
of hemorrhage in the brain parenchyma but without surface
laceration
 Neurological deficit which persists more than 24 hour
 Associated cerebral edema and defects in the blood brain
barrier

19. Cerebral laceration
 Severe degree of brain injury associated with a breach in the
surface parenchyma
 Tearing of brain surface may be due to skull fracture or due
to shearing forces
 Focal neurological defecit may be present

20. Extradural haematoma
 Collection of blood between the cranial bones and duramater
 It is associated with the fracture of temporo-parietal region
 Commonest vessel: Middle meningeal artery
 Lucid interval may be present
 Confusion, irritability, drowsiness, hemiparesis to the same side
of injury
 Hutchinson’s pupils
 Features of raised ICP: hypertension, bradycardia, vomiting

21.  CT scan: Biconvex lesion
 It is the surgical
emergency
 Craniotomy and
evacuation of clot is
done.

22. Sub Dural Haematoma
 Collection of blood between
brain and duramater
 Common intracranial mass
lesion resulting from trauma
Acute: <3 days
Sub-acute: 4-21 days
Chronic: >21 days

23. Sub Dural Haemotama
 Results from torn bridging vein or injury to the cortical
artery
 Haematoma extensive and diffuse
 No lucid interval
 Loss of consciousness occurs immediately after trauma and
is progressive
 Features of raised ICP and focal neurological defecits
 CT Scan: Concavo-convex lesion
 T/t: surgical decompression by craniotomy
 Antibiotics

24. Cerebral Herniation
 Increased ICP or presence of
intracranial mass may
predispose to cerebral
herniation.
 Herniation of contents of
supratentorial compartment
through the tentorial hiatus
 Herniation of the contents of
the infraintentorial
compartment through the
foramen magnum

25. Brain swelling
 It follows significant head
injury
 Occurs due to active
hyperaemia and edema
Infection, Seizure, Hydrocephalus

26. Approach to Head Trauma
 Detailed history should be sought in all cases of head
trauma.
 If the patient is unconscious which is usually the condition,
history should be obtained from the attendant.
 While one care provider is taking history, resuscitation
should be carried out simultaneously by other care provider.

27. Ask about:
 Type of accident: ?RTA, ?fall from height
?acceleration/deceleration injury during driving a motor car
 Level of consciousness: ?Unconscious, ?semiconscious
 If unconscious: duration of unconsciousness, ?immediately
after trauma ?lucid interval
 Post traumatic amnesia

28. Ask about:
 Vomiting: ?blood in vomitus ?persistent vomiting ?sign of
recovery from cerebral concussion
 Epileptic fits or seizure: Its nature may give clue to localization
of the site of trauma
 Swelling and pain in the head
 Other complaints: ?bleeding or watery discharge from ear,
nose and mouth

29. Ask about:
 Past history: ?fits or similar head injury in the past
?Hypertension ?DM ?Renal diseases
 Personal history: ?unconsciousness due to other cause
(alcohol, opium poisoning, diabetic coma)
 Family history: History of diabetes, HTN, epilepsy in the
family

30. Immediate management
 Initial assessment of head injuries must follow advanced
trauma and life support. (ALTS)
 It includes:
Maintenance of airway along with cervical spine control
Cervical spine immobilized in neutral position using neck
brace, sand bags, forehead tape
Suction of airway to clear blood, vomitus
Chin lift, jaw thrust
Oropharyngeal airway
ET tube, tracheostomy as necessary

31.  Maintenance of breathing
 Assessment of circulation and control of haemorrhage
 Establish iv access with two large bore iv cannulas
IV infusion of NS (Avoid 5% Dextrose as it may
precipitate cerebral edema)
 Assessment of dysfunction of CNS
 Exposure in a controlled environment
Remove all clothes and look for any obvious external
injury

32. Physical examination
 Pulse and blood pressure:
Pulse will be rapid, thready with low BP in case of cerebral
concussion
Pulse becomes slow and bounding with high BP in case of
cerebral irritation
Rapid pulse in deeply unconscious heralds impeding death

33.  Temperature:
In cerebral concussion, contusion temperature may remain
subnormal
With appearance of cerebral compression, temperature
may rise upto 100˚F
Victor Horsley’s sign

34. Physical examination
 Head:
Patient’s head must be shaved fully
Look thoroughly for any fracture of the skull, hematoma and
assess the type of fracture
Site of injury often gives clue towards the diagnosis.
 Position of the patient
 Eyes:
Is there any evidence of haemorrhage in and around the
eyes?
The condition of pupil

35. Neurological assessment
Neurological assessment can be done by using Glasgow coma scale.

36.  Minor head injury: GCS 15 with no loss of consciousness
(LOC)
 Mild head injury: GCS 14 or 15 with LOC
 Moderate head injury: GCS 9–13
 Severe head injury: GCS 3–8.

37.  Presence of neurological deficits:
Check for power, tone, superficial and deep tendon reflexes
 Rigidity of the neck:
May be present in the case of subarachnoid hemorrhage,
fracture dislocation of cervical spine
 Cranial nerve examination
Cranial nerve should be examined one after another
Of these most important is the third nerve
 Check for any other CNS manisfestation: ?Ataxia
?nystagmus

38. General Examination
Examine
 Chest for the fracture of the ribs, surgical emphysema
 Spine, pelvis and limbs for the presence of fracture
 Exclude abdomen for rupture of any hollow viscus, internal
haemorrhage form injury to any solid viscus eg: liver, spleen

39. Management:
 Place a Nasogastric tube to decompress the stomach and
reduce the risk of vomiting as aspiration
 Avoid NG tube for the patients with facial injuries as the
tube could enter the brain through bony fracture
 Insert an dwelling urinary catheter for hourly urine output
monitoring
 Avoid insertion if urethral injury suspected

40. Treatment of raised ICP
 IV Mannitol
 IV furosemide
 Reverse Trendelenburg if no counter
indications like hypovolaemia, spine injury
 If significant agitation and if hypoxia,
hypovolaemia or pain is excluded as the
cause of agitation: give IV Midazolam
 Analgesics for the pain management
 Phenytoin or phenobarbitone for post
traumatic seizure

41. Monitor
 Blood pressure
 Heart rate
 Respiratory rate
 Spo2
 ECG
 Blood samples for serum electrolyte Arterial blood gas
hyper/ hypoglycaemia

42. Special investigations!!!!
Definitive treatment!!!!

43. Complications
 Personality Changes
 Hypopituitarism e.g. DI
 Post-Traumatic Seizures
 Infections e.g.
Meningitis
 Vasospasm, Aneurysm
 Coma, Brain Death
Long-Term effects
 Parkinson’s
 Alzheimer’s Dementia

44. Rehabilitation
Physiotherapy
Occupational Therapy
Speech and Language Therapy
Psychologists/Psychiatrists

45. References
 SHORT PRACTICE of SURGERY Bailey & Love’s 25th Edition
 SRB Manual Of Surgery
 Death & Deduction Forensic Medicine
 A Manual On Clinical Surgery