Head injury
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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

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

  • 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


Aims

  • Prevent secondary brain injury

  • Rapid transfer to hospital


Brain Herniation


Uncal Herniation


Midbrain Infraction


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

  • Raised ICP

  • Reduced CPP

  • Loss of autoregulation

  • Neuroexcitotoxicity


Raised ICP

  • Seizures

  • Brain swelling

  • Vasogenic oedema

  • Intracranial haematoma

  • Hypercarbia

  • Hypoxia


Neurological Assessment

  • Level of consciousness (GCS)

  • Pupillary reaction to light

  • Limb movements

  • History


Complicating Factors

  • Alcohol

  • Drugs

  • Epilepsy

  • Stroke

  • Cervical spine injury


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

extension

no movement

Verbal (1-5)

orientated

confused

inappropriate words

incomprehensible sounds

none

GCS 3-15

Best score using upper limbs

Special cases

dysphasia

periorbital oedema

endotracheal tube/tracheostomy

The Glasgow Coma Scale and Score


Definition of Coma

  • GCS 8 or less

  • No eye opening

  • Does not speak

  • Does not obey commands


Dilated Pupil


Signs

  • 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


Panda Eyes


Battle’s Sign


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


Depressed Skull Fracture


Aerocoele


Penetrating Injury


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

  • 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


Haematoma


Contusion


Multiple Contusions


Extradural Haematoma


Subdural Haematoma


Chronic Subdural Haematoma


Diffuse Axonal Injury


Extradural Haematoma


Skin Preparation


Craniotomy Mark


Opening


Dura


Subdural Haematoma


Subdural Collection


Haemostasis


Monitoring


ICP Monitoring


GCS Chart


Outcome at 1 year


Outcome wrt Haematoma


Recovery


Use of Helmets


Head Injury Management


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