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Head Injury. Saurabh Sinha Department of Clinical Neurosciences Western General Hospital. Age Groups. Mechanisms of Injury. What now?. Resuscitation. Aairway with cervical spine control Bbreathing Ccirculation. Traumatic Brain Injury. Immediate impact injury

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Head Injury

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Head injury

Head Injury

Saurabh Sinha

Department of Clinical Neurosciences

Western General Hospital

Age groups

Age Groups

Mechanisms of injury

Mechanisms of Injury

What now

What now?



  • Aairway with cervical spine control

  • Bbreathing

  • Ccirculation

Traumatic brain injury

Traumatic Brain Injury

Immediate impact injury

  • Contusions and lacerations

  • Diffuse damage to white matter

  • Other types of diffuse brain injury

    Primary complications

  • Intracranial haemorrhage

  • Brain swelling

    Secondary complications

  • Brain damage secondary to raised ICP

  • Hypoxic brain damage

  • Infection

Head injury


  • Prevent secondary brain injury

  • Rapid transfer to hospital

Brain herniation

Brain Herniation

Uncal herniation

Uncal Herniation

Midbrain infraction

Midbrain Infraction

Cerebral physiology

Cerebral Physiology

  • Intracranial pressure (ICP) 0-10 mmHg

  • Cerebral perfusion pressure (CPP) >60 mmHg

  • Obligative aerobic glycolysis

  • Cerebral blood flow (CBF) maitained by autoregulation

Severe head injury

Severe Head Injury

  • Raised ICP

  • Reduced CPP

  • Loss of autoregulation

  • Neuroexcitotoxicity

Raised icp

Raised ICP

  • Seizures

  • Brain swelling

  • Vasogenic oedema

  • Intracranial haematoma

  • Hypercarbia

  • Hypoxia

Neurological assessment

Neurological Assessment

  • Level of consciousness (GCS)

  • Pupillary reaction to light

  • Limb movements

  • History

Complicating factors

Complicating Factors

  • Alcohol

  • Drugs

  • Epilepsy

  • Stroke

  • Cervical spine injury

The glasgow coma scale and score

Eye (1-4)

open spontaneously

open to speech

open to pain

no opening

Motor (1-6)

obeys commands

localises to pain

normal flexion

abnormal flexion


no movement

Verbal (1-5)



inappropriate words

incomprehensible sounds


GCS 3-15

Best score using upper limbs

Special cases


periorbital oedema

endotracheal tube/tracheostomy

The Glasgow Coma Scale and Score

Definition of coma

Definition of Coma

  • GCS 8 or less

  • No eye opening

  • Does not speak

  • Does not obey commands

Dilated pupil

Dilated Pupil



  • Penetrating Injury

  • Scalp laceration or haematoma

  • Periorbital haematoma

  • Blood or CSF from nose

  • Blood or CSF from ear

  • Battle’s sign

  • Cranial Nerve (eye movements, facial weakness)

Subconjunctival haemorrhage

Subconjunctival Haemorrhage

Panda eyes

Panda Eyes

Battle s sign

Battle’s Sign

Indications for skull x ray

Indications for skull X-ray

  • Orientated Patients

    • History of LOC/amnesia

    • Suspected penetrating injury (?CT)

    • CSF/Blood from ear/nose

    • Scalp laceration (to bone or >5cm), bruise or swelling

    • Persistent headache or vomiting

    • Children

      • Fall from significant height

      • Onto hard surface

      • Tense fontanelle

      • Suspected NAI

  • Patients with impaired consciousness or neurological signs

    • All patients unless CT or neurosurgical transfer arranged

Skull fracture

Skull Fracture

Depressed skull fracture

Depressed Skull Fracture



Penetrating injury

Penetrating Injury

Risk of operable intracranial haematoma in head injured patients

Risk of operable intracranial haematoma in head injured patients

  • GCS 15 (1:3615)1 in 31300

    • With PTA1 in 6700

    • Skull fracture1 in 81

    • Skull fracture & PTA1 in 29

  • GCS 9-14 (1:51)1 in 180

    • Skull fracture1 in 5

  • GCS 3-8 (1:7)1 in 27

    • Skull fracture1 in 4

Indication for urgent ct ns referral

Indication for urgent CT/NS referral

  • Coma persisting after resuscitation

  • Deteriorating conscious level or progressive neurological signs

  • Skull fracture & confusion/seizure/neuro symptoms or signs

  • Open injury: compound depressed #, gunshot or penetrating injury





Multiple contusions

Multiple Contusions

Extradural haematoma

Extradural Haematoma

Subdural haematoma

Subdural Haematoma

Chronic subdural haematoma

Chronic Subdural Haematoma

Diffuse axonal injury

Diffuse Axonal Injury

Extradural haematoma1

Extradural Haematoma

Skin preparation

Skin Preparation

Craniotomy mark

Craniotomy Mark



Head injury


Subdural haematoma1

Subdural Haematoma

Subdural collection

Subdural Collection





Icp monitoring

ICP Monitoring

Gcs chart

GCS Chart

Outcome at 1 year

Outcome at 1 year

Outcome wrt haematoma

Outcome wrt Haematoma



Use of helmets

Use of Helmets

Head injury management

Head Injury Management

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