Head injuries

1. Head injuries

4. A head injury is any trauma that leads to injury of the scalp, skull, or brain. These injuries can range from a minor bump on the skull to a devastating brain injury.

5. Head injury can be classified as either closed or penetrating. • In a closed head injury, the head sustains a blunt force by striking against an object • In a penetrating head injury, an object breaks through the skull and enters the brain. (This object is usually moving at a high speed like a windshield or another part of a motor vehicle.)

6. Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life. • In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.

7. Pathophysiology • Direct trauma. • Cerebral contusion. • Intracerebral shearing. • Cerebral edema. • I.C.H • Hydrocephalus

8. Traumatic Head Injury

9. Cerebral Edema • Cellular response to injury • Primary injury • Secondary injury • Hypoxic-ischemic injury • Injured neurons have increased metabolic needs • Concurrent hypotension and hypoxemia • Inflammatory response

10. The main factors which determine the severity of cerebral injury are: • Distortion of the brain. • Mobility of brain in relation to skull and meninges. • Configuration of interior of skull. • Deceleration and acceleration. • The pre-existing state of brain (elderly).

11. Brain injury: • Concussion. • Temporary dysfunction which resolves after a variable period • Amnesia is common

12. Contusion & Laceration • Small areas of hemorrhages • Usually produce neurological deficits that persist for longer than 24 hours • Diffuse axonal head injury • As a result of mechanical shearing following deceleration, causing disruption and tearing of axons

13. The Secondary pathology: • Intracranial : • Brain swelling, oedema. • Necrosis. Ischemia. • Hematoma. • Metabolic or endocrine disturbances. • Coning. • Coup & Counter-coup. • Infection • Epilepsy

14. Extracranial : • Resp. failure, increase CO2. • Systemic B/P • Fluid, isotonic. • Temperature

15. Skull fractures • Simple fracture. • Comminuted linear fracture of the vault. • Skull base fracture. • Depressed fracture. by: -falling objects. -Assault with a heavy blunt tool. -Missile injury. -R.T.A

17. Skull base fracture • Diagnosed on clinical bases. • They often result in CSF leak. • Rhinorrhoea • Anosmia • C-C fistula • Periorbital hematoma • CSF otorrhoea • Battle`s sign

18. Compound depressed fracture: • Antibiotics. • Anti tetanus prophylaxis. • Surgery. Urgent. • Closed depressed fracture

19. Closed depressed fractureIndication of surgery: • Dural tear • Brain compression... (Dural venous sinuses.) • Cosmetic.

20. Missile injuries: • Scalp injury. • Depressed skull fracture. • I.C.H. • Brain injury.

21. Management of Traumatic Head Injury • Maximize oxygenation and ventilation • Support circulation / maximize cerebral perfusion pressure CPP=MSP-ICP • Decrease intracranial pressure • Decrease cerebral metabolic rate

22. Monitoring • Serial neurologic examinations • Circulation / Respiration • Intracranial Pressure • Radiologic Studies • Laboratory Studies

23. Circulatory Support: Maintain Cerebral Perfusion Pressure Number of Hypotensive Episodes Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)

24. Lowering ICP Brain Blood • Evacuate hematoma • Drain CSF • Intraventricular catheters use is limited by degree of edema and ventricular effacement • Craniotomy • Permanence, risk of infection, questionable benefit CSF Mass Bone

25. Reduce edema • Promote venous return • Reduce cerebral metabolic rate • Reduce activity associated with elevated ICP

26. Management on head injuries • Minor head injury

27. For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. • The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness

28. Indications for admission to hospital: • Loss of consciousness. • Persistent drowsiness. • Focal neurological deficit. • Skull fracture. • Persisting nausea & vomiting • Elderly & infant. • W.

29. Signs of deterioration: • Becomes unusually drowsy • Develops a severe headache or stiff neck • Vomits more than once • Loses consciousness (even if brief) • Behaves abnormally

30. If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.

31. Management • Observation. • Bed elevated 20. • Mild fluid restriction.

32. Severe head injury • It depends on the patient’s neurological state and the intracranial pathology resulting from the trauma. • Clinical assessment and CT scan • Evacuation of any hematomas

33. If there is no surgical lesion, or following the operation: • Observation and GCS chart • Decrease intracranial brain swelling • Airway management • Elevation of the head of the bed 20º • Fluid and electrolyte balance • Blood replacement with colloid or blood and not crystalloid • No steroids

34. Management of conditions resulted from head injury • Severe hyponatraemia due to excessive fluid intake or inappropriate excessive secretion of ADH • Hypernatraemia due to inadequate fluid intake. • Diabetes insipidus

35. Temperature control, pyrexia due to hypothalamic damage or traumatic SAH or infection or from CSF leak and meningitis

36. Nutrition: • During the initial 2-3 days the fluid therapy will include 1.5-2 liters of 5% dextrose • After 3-4 days by nasogastric feeding

37. Routine care of the unconscious patient, bowel, bladder and skin. • Intracranial monitoring in more severe cases.