HEAD INURY

Dr Mukhilesh R M.S

Salient features of Head Injury

Most common cause of death following road traffic accidents.

Outcome of traumatic brain injury

not only personal loss

neuro-reahabilitaion

long term nursing care

supportive care

Pathophysiology of brain Injury

Cerebral autoregulation

normal blood flow – 55ml/100g/minmean arterial pressure 50-150 mmHg

Monroker Kelle Doctrine ????

Primary vs Secondary brain Injury

Primary brain Injury

At the time of impactBrainstem and hemispheric

contusionsDiffuse axonal injuryCortical lacerations

Primary vs Secondary brain Injury

Secondary brain Injury

sometime after the impactoften preventablecauses

Hypoxia PO2<8kPaHypotension SBP<90mmhgRaised ICP >20mmhgPyrexiaCerebral Perfusion Pressure

<65mmhgMetabolic Disturbances

Classification Of Head Injury

Blunt vs Penetrating

Morphological

Skull FracturesVault –

open / closed linear / communiteddepressed / non depressed

Base of skull fracture

Intracranial Hematoma

EDH / SDH/ SAH/ ICH

Clinical Features

Rule out multisystem injury esp spinal injury

Rule out non accidental causes of collapse

syncopeaneurysmal SAHhypoglycemiaelectrolyte imbalancemedications and drug abuse

Clinical Features

A – Airway

B- Breathing

C- Circulation

D- Disability assesment

Pupils and GCS

Glasgow Coma Scale - GCS

Racoon Eyes

Battle’s Sign

Dilated Pupil

NICE guideline for computed tomography (CT)

GCS <13Focal Neurological deficitSuspected open, depressed or basal skull fractureSeizureVomiting >1 episode

Urgent CT even if none of the above

Age>65coagulopathyantegrade amnesia >30 min

Extradural hematoma

Neurosurgical emergency

Associated with skull fracture

Tearing of meningeal artery

PTERION – middle meningeal

Can also be dural venous bleed

LUCID INTERVAL

Extradural hematoma

LENTIFORM SHAPE

MASS EFFECT

Management

Burr Hole evacuation of hematoma

Subdural Hematoma

disruption of cortical vessel or brain laceration

significant primary brain injury

impaired conscious level

diffuse and concave appearance in CT

Poor prognosis

CONVEX SHAPE

Clinical Features

Small hematomas with little mass effect – conservative management

Surgery inappropriate

best GCSpupillary

reactivityageanticoagulant

drugs

Subarachnoid hemorrhage

Aneurysms and trauma

Traumatic SAH – conservative Rx

Chronic SDH

Elderly / anticoagulant

Tear in small bridging veins and samll ASDH – silent

Hematoma breaks down – mass effect

Headache / ICT increased/ focal deficits

Rx – evacuation via Burr Hole

Cerebral Contusions

Coup injury

Contre coup injury

ICP

Cerebral perfusion pressure = MAP- ICP

CPP to be maintained >65mmhg

ICP >20 mmhg – poor outcome

ICP monitoring – ventricular or parenchymal

ICP

Sedation

Diuretics

Thermoregulation – pyrexia increases brain metabolism

Barbiturates – thiopentones

Seizure control

Decompressive craniectomy

Skull fractures

Vault fractures

elevation of depressed segments

wound debridement

Base of skull fractures

CSf rhinorhoea or otorrhoea

anterior fossa dural repair

Long term sequelae

Neurorehabilitation

Pyschological support

Seizures

TRAUMATIC BRIN INJURY IS A PREVENTABLE CAUSE