Head Injuries
Head Injuries
Outline
Define and classify head injury
Relevant signs and symptoms of head injury
Obtain history on patients presented with head
injury
Give differential diagnosis of head injury
Perform examination of the head injury
Identified the initial investigation and management
To know when and how to refer the patient to
surgical for head injury
Definition
Head injury is a broad term that describes a
vast array of injuries that occur to the scalp,
skull, brain, and underlying tissue and blood
vessels in the head.
Anatomy
Head Injury
Skull
Brain
Traumatic
Brain Injury
(TBI)
Traumatic
Parenchym
al Injury
Concussion
Contusion
Acquired
Brain Injury
(ABI)
Traumatic
Vascular
Injury
Diffuse
Axonal
Injury
Epidural
Hematoma
Coup
Subdural
Hematoma
Contrecoup
Subarachno
id
Hematoma
Coupcontrecoup
Levels of
Brain Injury
Linear
Scalp
Depressed
Anoxia
Mild
Vault
Open
Hypoxic
Moderate
Basilar
Closed
Severe
Mild
Glasgow Coma Scale (GCS) score 13-15
Stunned or dazed for a few seconds or minutes
Remains alert without post-traumatic amnesia
(PTA)
Headache can follow
Complete recovery is usual
Moderate
GCS score 9-12
Usually result from a non-penetrating blow to the head, and/or
a violent shaking of the head
A loss of consciousness lasts from a few minutes to a few hours
Confusion lasts from days to weeks
Physical, cognitive, and/or behavioral impairments last for
months or are permanent
Good recovery with treatment or successfully learn to
compensate for their deficits
Severe
GCS score 3-8
Usually result from crushing blows or
penetrating wounds to the head
PTA of more than 24 hours
Coma with no meaningful response and no
voluntary activities lasts days, weeks, or
months
Skull Fractures
Any break in the skull
Type of skull fracture depends on :
- the force of the blow
- the location on the skull at which the impact
occurs
- the shape of the object making impact with the
head
Only one cause: an impact or a blow to the head that
is strong enough to break the bone
Two major types of skull fractures :
- Linear
Closed fractures
Simple fractures
Skin is not broken or cut
Scalp Injury
Scalp is the highly vascular skin that cover and
protect the skull
may manifest as abrasion, bruising, laceration, or a
burn
may lead to bleeding or tissue damage
Sensory symptoms
Blurred vision
Ringing in the ears
A bad taste in the mouth or
changes in the ability to smell
Sensitivity to light or sound
Cognitive or mental
symptoms
Memory or concentration
problems
Mood changes or mood
swings
Feeling depressed or anxious
Cognitive or mental
symptoms
Persistent headache or
headache that worsens
Repeated vomiting or
nausea
Convulsions or seizures
Inability to awaken from
sleep
Weakness or numbness in
fingers and toes
Profound confusion
Agitation, combativeness or
other
unusual behavior
Slurred speech
Coma and other disorders of
consciousness
DIFFERENTIA
L DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Stroke
Cardiac Arrest
Hypertensive Encephalopathy
Basilar Artery Thrombosis
Cerebral Venous Thrombosis
Seizure
HISTORY
TAKING
HISTORY TAKING
After initial resuscitation and management of ABCDs,
a focused history should be performed on every
patient with a TBI or unknown cause of altered
mental status.
A detailed description of the traumatic event should
be solicited from the patient, family members, first
responders, or police.
Witnesses or individuals who know the patient may
be helpful in ascertaining the details of the traumatic
event and environment, as well as the patients
normal level of functioning.
It is important to keep the differential diagnoses
broad to avoid making an error of premature closure.
CNS Review
Physical
Examination
Physical Examination
A thorough physical examination must be
performed after the initial ABCDs have been
addressed.
In addition to vigilance for occult injuries, the
physician should perform the physical
examination with careful attention to the
following:
Serial GCS and pupillary examinations should
be performed every 15 minutes until the
patient is stable, to immediately identify
deterioration in neurological function.
- GCS of 13 to 15 is
- GCS of with
13 to
15 brain
is
associated
mild
associated with mild
injury
brain injury
- GCS of 9 to 12 is
- GCS of 9 to 12 is
associated with moderate
associated with
brain injury
moderate brain injury
- GCS of <8 is associated
- GCS of <8 is associated
with severe brain injury.
with severe brain injury.
Pupil reflex
Pupillary reflexes function as an indication of both
underlying pathology and severity of injury, and should
be monitored serially.
Pupils should be examined for size, symmetry,
direct/consensual light reflexes, and duration of
dilation/fixation.
Abnormal pupillary reflexes can suggest herniation or
brainstem injury.
Orbital trauma, pharmacological agents, or direct
cranial nerve III trauma may result in pupillary changes
in the absence of increased ICP, brainstem pathology,
or herniation.
Pupil Size
The normal diameter of the pupil is between
2 and 5 mm, and although both pupils
should be equal in size, a 1-mm difference
is considered a normal variant.
Abnormal size is noted by anisocoria
defined as >1 mm difference between
pupils.
Pupil Symmetry
Normal pupils are round, but can be
irregular due to ophthalmological surgeries.
Abnormal symmetry may result from
compression of CNIII can cause a pupil to
initially become oval before becoming
dilated and fixed.
INVESTIGATI
ON
1. CT Head Scan
For adults who have sustained a head injury and
have any of the following risk factors, perform a
CT head scan within 1 hour of the risk factor
being identified:
GCS less than 13 on initial assessment in the
emergency department.
GCS less than 15 at 2 hours after the injury on
assessment in the emergency department.
Subdural Hemorrhage
Example of imaging
2. CT Cervical Scan
For adults who have sustained a head injury and
have any of the following risk factors, perform a
CT cervical spine scan within 1 hour of the risk
factor being identified:
GCS less than 13 on initial assessment.
The patient has been intubated.
Plain X-rays are technically inadequate (for
example, the desired view is unavailable).
Plain X-rays are suspicious or definitely abnormal.
A definitive diagnosis of cervical spine injury is
needed urgently (for example, before surgery).
3. MR Imaging
MR imaging is indicated if there are
neurological signs and symptoms referable to
the cervical spine.
If there is suspicion of vascular injury (for
example, vertebral malalignment, a fracture
involving the foramina transversaria or lateral
processes, or a posterior circulation
syndrome), CT or MRI angiography of the neck
vessels may be performed to evaluate for this.
4. Angiogram
6. Blood test
All patients with multiple injuries and those with
severe head injuries, should have blood samples
analysed for baseline estimations - full blood
count, electrolytes and urea, coagulation
screen, blood gases, alcohol level and blood
group (and save).
Electrolyte abnormalities and haemoglobin
deficiencies should be corrected, if present,
whilst clotting disorders should be corrected if
surgery is anticipated.
MANAGEME
NT
1. Transfer to hospital
Patients who have sustained a head injury should be
refered to a hospital emergency department, using
the ambulance service if deemed necessary, if any
of the following are present:
Glasgow coma scale (GCS) score of less than 15 on
initial assessment.
Any loss of consciousness as a result of the injury.
Any focal neurological deficit since the injury.
Any suspicion of a skull fracture or penetrating head
injury since the injury.
Amnesia for events before or after the injury
2. Emergency Management
Remember that the priority for all emergency
department patients is the stabilisation ABCDE
before attention to other injuries.
Airway
Breathing
Circulation
Disability
Exposure
AIRWAY
Handle Neck With Caution: Assume C-spine Injury
Attempt full cervical immobilisation
Avoid Obstruction of Venous Drainage
Do oral intubation if GCS < 8
May Need to Protect Airway Due to Seizures or
Trauma
BREATHING
Even a small rise in PaCO2 causes a significant
rise in ICP
Adequate breathing may not be enough- aim
for PaCO2 of 35-40 mmhg
Hyperventilation is the quickest way to lower ICP
if there are signs of herniation
CIRCULATION
Blood pressure must be optimized to help
maintain adequate CPP (Cerebral perfusion
pressure)
Prevent increased ICP by administering
Mannnitol IV
Only use isotonic fluids for volume expansion
May need inotropic or pressor support
Control bleeding
DISABILITY
Neurological examination begins with
assessment of the patients conscious level
using the GCS.
The severity of the head injury can be based on
this initial GCS score.
A patient with a GCS of 8 or less is in need of
urgent anaesthetic assessment as airway
compromise and/or reduced lung ventilation is
likely.
3. Pain Management
Manage pain effectively because it can lead to a
rise in intracranial pressure.
Provide reassurance, splintage of limb fractures
and catheterisation of a full bladder, where
needed. Treat significant pain with small doses
of intravenous opioids titrated against clinical
response and baseline cardio respiratory
measurements
Indications
for surgery
Epidural Hematoma
Surgery is Indicated
If volume > 30 cm3
Subdural Hematoma
Surgery is Indicated If
size > 10 mm on CT or if 5
mm shift
1st line
Irrigation/evacuation via
burr twist drill and burr
hole craniostomy
2nd line Craniotomy
References
Printed Materials
T. Flannery And N. Buxton (2001) . Modern
management of head injuries. J.R.Coll.Surg.Edinb.,
46, June 2001, 150-15.
http://www.rcsed.ac.uk/RCSEDBackIssues/journal/vol46_
3/4630005.htm
M.Longmore, I.B. Wilkinson, A.Baldwin and E. Wallin
(2014). Oxford Handbook of Clinical Medicine (9th
Edition). Oxford University Press, New York.
Vinay Kumar, Abul K.Abbas, Jon C.Aster (2013). Robbins
Basic Pathology, 9th Edition. Elsevier Saunders.
Parveen Kumar, Michael Clark (2009). Kumar & Clarks
Clinical Medicine, 7th Edition. Elsevier Saunders.
References
Websites
http://biau.org/types-and-levels-of-brain-injury/
http://www.uchospitals.edu/onlinelibrary/content=P00785
http://emedicine.medscape.com/article/248108overview#a7
http://www.mayoclinic.org/diseases-conditions/tr
aumatic-brain-injury/basics/symptoms/con-2002930
2
https://www.traumaticbraininjuryatoz.org/MildTBI/Diagnosing-Mild-TBI-Concussion/Imaging-Tests