HI is the most common cause of trauma related mortality.

1
Introduction

• HI is the most common cause of trauma related
  mortality.
• Motor vehicular accidents account for more than
  60 of the trauma
• Head injury is the leading cause of disability

2
Classification

• Based on the injury type
• closed
• No wound
• Penetrating (e.g. gun shot, knife , nail gun)
• Prognosis is better if the lesion was away from
  the brain stem , or vital structure , or patient
  had been managed early
• The silent area of the brain is the frontal lobe
  , cause it doesnt exert vital function

3
Classification

• Anatomically head injury can be classified
• Scalp injury significant in neonates
• Bone injury skull fracture
• Brain injury

4
Classification

• Based on severity
• Mild
• Moderate
• Severe
• Its measured by GCS, or roughly by TLC,
  (transient loss of consciousness ) temporal
  parameter

5
Classification

• Based on the extension of the injury
• Primary injury
• Occurs at the time of trauma and localized to
  the site of trauma except for DAI where the
  injury is all over the brain .
• Difficult to treat and obviously not preventable

6
Classification

• Secondary injury
• Occurs when the local process within the skull or
  systemic reaction worsen the initial injury and
  cause further damage.
• Local process include
• Intracranial Hrg
• Local or diffuse brain swelling
• Increase in ICP
• Decrease in cerebral perfusion flow
• Infection , hydrocephalus
• Systemic reaction includes
• Hypoxia
• Hypotension
• Anemia

7
Classification

• Cont.
• Relatively its worse than the primary injury but
  it could be preventable or even curable so it
  should be the focus of head trauma management
• The severity of brain damage doesn't correlate
  directly with the severity of the primary injury
  (mild injury to a major vessel shock global
  brain damage)

8
Types of brain injury(pathophysiology)

• Diffuse brain injury
• Concussion a diffuse brain injury associated
  with brief loss of neurological function with
  little or no apparent cerebral tissue damage .
  This injury is exceedingly common.
  unconsciousness is usually short (min) and
  usually disappears before the patient gets to the
  hospitals . There is usually some degree of PTA .
  Concussion represent 59 of head injury
• Diffuse axonal damage (DIA) a diffuse axonal
  injury caused by microscopic damage distributed
  throughout the brain. Its often referred to as a
  closed head injury , or brain stem injury .coma
  is present for days or even weeks . Mortality
  rate can be as high as 50.CT scan shows no mass
  lesion .treatment is mainly nonsurgical , with
  control of ICP. It represent 44 of severe
  (GCS) head injuries

9
Types of injury Con.

• Focal brain injury
• Contusion a focal injury that is directly
  related to the site of impact (coups contusion)
  or an area remotely related to the point of
  impact (countercoup contusion). The tips of
  frontal and temporal lobes are frequently
  involved .
• focal deficits , confusion ,obtundation , and
  coma can be seen. It represent about 15 of HI
• Acute hemorrhage
• Epidural hemorrhage usually the result of a
  tear in the middle meningael artery. Classical
  signs are loss of consciousness followed by a
  lucid interval (concussion), then depressed
  consciousness and contra lateral hemi paresis.
  The prognosis is usually good because there is
  minimal underlying brain injury . Treatment is
  evacuation of hematoma .it represent 0.5of head
  injuries
• Subdural hemorrhage caused by ruptured bridging
  veins , tears in cortical arteries ,or cerebral
  laceration . Clinical problems are caused by
  severe underlying brain injury as well as mass
  effect . It accounts for about 30 of head
  injuries.
• Sub arachnoid hemorrhage the most common
  intracranial hemorrhage . It is caused by injury
  to vessels in the pia that bleed into the
  cerebrospinal fluid , producing irritation
  (headache , stiff neck ) it has little surgical
  significance by itself cause the blood
  distributes throughout the subarachinoid space
  and no mass effect is produced .
• Intra cerebral hemorrhage severe brain injury
  . Its commonly associated with DIA , cerebral
  laceration and gun shot wounds

10
Types of brain injury Con.

• Brain Herniation
• It should be taken seriously
• You have to check signs of lateralization
• Types of herniation based on the site
• Subfalcial
• Transtentorial
• Central
• External
• Tonsillar

11
Glasgow Coma Scale

• The Glasgow Coma Scale is a neurological scale
  which aims to give an reliable, objective way of
  recording the conscious state of a person, for
  initial as well as continuing assessment
• A patient is assessed against the criteria and
  the resulting points give the Glasgow Coma Score

12
Glasgow Coma Scale
13
Glasgow Coma Scale

• Generally, comas are classified as
• Severe, with GCS 8
• Moderate, GCS 9 - 12
• Minor, GCS 13.
• Highest score is 15/15.the person in this case is
  alert and oriented to person, place and time
• Lowest score is 3/15 theres no 0.The patient is
  in deep coma and is considered brain dead if he
  cant breath without a ventilator

14
Investigations

• To begin with any comatosed patient after trauma
  is treated as cervical spine fracture until
  proven otherwise, 4 people should carry the
  patient supporting him on a hard board with a
  neck collar strapped on and no twisting and
  bending
• The initial investigations are similar to the
  basic investigations performed on any unconscious
  patient after trauma and these are the standard
  x-rays of the cervical dorsal and lumber spine in
  addition to pelvic and chest x-rays.
• An x-ray should also be taken in any part of the
  body with a suspected fracture

15
Investigations

• The main stream investigation in case of head
  injury is a CT scan of the brain
• In the CT fresh blood is White (hyperdense) as
  blood gets older it becomes black (hypodense)
  this takes 3-4 weeks to occur
• CSF and air are black (hypodense)

16
Investigations

• Brain CT Ex
• Extradural Hematoma
• An extradural hematoma is usually lens shaped
  (biconvex)

17
Investigations

• Brain CT Ex
• 2. Subdural Hematoma
• A subdural hematoma is usually crescent shaped
• A subdural hematoma can be acute or chronic

18
Investigations

• 3. Intra cerebral hemorrhage CT head scan
  showing right intracerebral hemorrhage secondary
  to ruptured right middle cerebral aneurysm

19
Investigations

• 4. Subarachnoid hemorrhage CT head scan
  demonstrating large subarachnoid hemorrhage(SAH).
  Note small amount of blood in the bottom of the
  left lateral ventricle

20
Investigations

• Finally if needed an ultrasound of the abdomen
  and a CT scan of the chest and abdomen may be
  performed

21
Management of head injuries

• ABCs
• Intubation of a comatose patient is done with
  inline immobilization of cervical spine.
• Emergency cervical fracture suspected ?
  Orotracheal intubation with inline neck
  stabilization.
• A nasogastric tube is avoided if a ciribriform
  plate or paranasal skull base fracture is
  suspected. Orogastric intubation is recommended.
• Control of Blood pressure. (hypotension, reflex
  hypertension).
• Use of colloid infusion is preferred.
• Pure dextrose solutions are contraindicated
  because they might exacerbate cerebral edema and
  increase ICP.

22
Management of head injuries

• 2. Neurological Evaluation
• Previously explained.
• Treat ICP.
• Seizures may increase both ICP Hemorrhage.
  Emergency treat with IV Diazepam (0.2mg/kg)
  followed by a slow infusion of phenytoin (15mg/kg
  at 0.6mg/kg/min)
• 3. Radiological Evaluation
• Previously explained.
• An ICP monitor may be inserted to monitor
  patients who have scores of 8 or less on the
  Glasgow scale

23
Management of head injuries

• 4. Treatment of acute Injuries
• 1. Direct Brain Injury
• Adequate Oxygenation and Perfusion.
• Treat ICP. ? To prevent further brain
  injury.
• 2. Intracranial Hematomas
• Epidural Subdural Craniotomy for evacuation
  (unless very thin)
• Intraparenchymal No warranty for surgery.
• Treat increased ICP medically.

24
Management of head injuries

• 3. Skull fractures
• Closed linear fractures require no direct
  treatment.
• Simple closed depressed fractures Surgical
  elevation, usually limited to depressions that
  are greater than the thickness of the skull are
  not located over major venous sinuses.
• Compound linear fractures Debridement
  Antibiotics
• Compound depressed fractures Elevation
  Debridement in the OR on an urgent basis 6
  hours Antibiotics.
• Basilar fractures No emergency operation.
• Bed rest, head at constant modest
  elevation (45)
• Prophylactic antibiotics.
• Lumbar spinal subarachnoid drainage if
  there is persistent CSF leakage

25
Management of head injuries

• 4. Penetrating Injuries
• Require debridement, treated similarly to
  compound depressed fractures.
• Require urgent surgery to prevent abscess
  meningitis.
• 5. Simple scalp laceration
• Early irrigation.
• Debridement.
• Single-Layer skin closure

26

• 5. Treatment of Subacute chronic injuries
• 1.Chronic Subdural Hematomas
• Usually in young children
• Regular removal of hematoma fluid with subdural
  taps eliminates the need for surgical drainage or
  a shunt procedure
• 2. CSF Leak
• Treat meningitis with antibiotics.
• After successfully treating meningitis ? Surgical
  treatment
• 3. Growing Fracture
• Surgical Repair.
• Delayed Cranioplasty is necessary to repair skull
  defects after decompressive craniectomy or
  removal of a compound depressed skull fracture.