HEAD INJURYPRESENTERS: DANNY

FARAHANA

SUPERVISED BY: DR. NITHYA RAMANATHAN

Layout Aims Outline

◦Definition◦Pathophysiology◦Characterization of TBI◦Management

Take home messages

Aim To understand

◦ Definition of head injury◦ Simple pathophysiology related to head injury◦ Classification of pathology related to head injury◦ Basic approaches toward head injury

Definition

Head injury / Traumatic brain injury◦ “any alteration in mental or physical functioning related

to a blow to the head”◦ “Loss of consciousness does not need to occur”

source: David A Olson. Head injury [internet] 2013 [updated Apr 1 2013] available from http://emedicine.medscape.com/article/1163653

AnatomySCALPS - SkinC - Close connective tissue & cutaneous vessels & nerves.A - Aponeurosis (epicranial aponeurosis)L - Loose connective tissue P - Pericranium (periosteum of skull bones)

Laceration wound of scalp – STO day 7-10Non-absorbable suture

Pathophysiology Primary head injury

◦ Direct result of the trauma◦ The initial structural injury due to impact

Secondary head injuryo Any subsequent injury to brain after initial insult

o Eg: hypotension, hypoxia, increase ICP, neurochemical changes

A blow to the skull results in compression injury to the adjacent brain (coup) and stretching on the opposite side (contrecoup).

Physiology

Brain Cerebrospinal fluid Blood

• Skull is a close box, inelastic– Contents:

• Monro–Kellie doctrine:– sum of volumes of brain, CSF, and intracranial

blood is constant and incompressible– Increase in volume can lead to significant raised

in ICP (eg: cerebral edema, hematoma)– Brain has limited compliance

Normal adults-total intracranial volume 1.5L-brain 85-80%-blood 10%CSF <3%

Pressure change

Brain has very limited compliance and cannot tolerate significant increases in volume that can result from diffuse cerebral oedema or from significant mass lesions such as a hematoma

Volume change

Cerebral perfusion pressure (CPP)◦ The difference between the mean arterial pressure

(MAP) and the ICP

◦ Normal person without long standing HPT or brain injury, CPP range = 50-150mmHg

◦ Autoregulation controls blood pressure to maintain constant blood flow to the brain

◦ CPP too low = ischemic◦ CPP too high = hyperemic

CPP = MAP - ICP

Characterization of TBI Pathology

◦Cerebral concussion◦Skull fracture◦Surgical lesions◦Diffuse injuries

Cerebral Concussion Definition

◦ Physiological dysfunction without anatomical or radiological abnormality

Symptoms◦ Transient loss of consciousness (usually regain full

conscioness by < 6hours ◦ + post traumatic amnesia (anterograde / retrograde)

Most patient are without sequelae

Skull fracture Linear Depressed

◦ Simple (closed)/compound(open)

Basal Skull fracture Craniofacial fracture

Linear skull fractureLinear skull fracture vs suture line (on Xray)

Feature Linear skull fracture Suture line

Density Dark black Grey

Course Straight Follows course of suture line

Branching None Joins other suture line

Width Very thin Jagged, wide

Right normalLeft fracture

Basal Skull fracture

transverse temporal bone fracture.

longitudinal temporal bone fracture

Basilar skull # features:• Racoon eyes (bleed around

eyes)• Battle sign (bleed behind

ears)• CSF leak from nose or ear• Persistent ENT bleed• Subconjunctival

hemorrhage with no posterior limit

Ryles tube insertion contraindicated

Start antibiotics to prevent meningoencephalitis

Depressed Skull fracture

Depressed skull fracture CT scan

Depressed skull fracture CT scan

Craniofacial fracture (Lefort classification)Lefort Brief description

I Transverse / transmaxillary fracture – crosses pterygoid plate and maxilla

II Pyramidal – extends upward across inferior orbital rim and orbital floor to medial orbital wall.Often due to downward blow to nasal area

III Craniofacial dislocation

Intracranial Hematoma

Extradural Bleed Subdural Bleed Subarachnoid Bleed Contusional bleed

Extradural Bleed Location

◦ Between inner skull layer and outer dura layer

Commonly:◦ Temporo-parietal area◦ Middle meningeal artery tear

Phases1. Brief post traumatic LOC2. Lucid interval for several hours3. Obtundation, contralateral hemiparesis, ipsilateral pupillary dilatation

CT scan:◦ Bi-convex hyperdense lesion◦ Heterogenous◦ Sharply demarcated

Extradural bleed 40% of lesion will not be seen on Skull Xray Mortality

◦ 20-50% without treatment◦ 5% with surgical treatment

Indication for conservative treatment◦ <1.5 cm bleed◦ No midline shift◦ No neurological deficit

Subdural Bleed Location:

◦ Between dura and arachnoid mater

Acute (1-3d) / Chronic (> 2 weeks)

Pathophysio:1. Accumulation of blood around parenchymal

laceration2. Surface of bridging veins torn during violent head

motion

Common location◦ Fronto-parietal convexities and middle cranial fossa

CT scan◦ Crescent-shaped, hyperdense, homogenous (density increases when clot retract)

Subarachnoid Bleed Location:

◦ Within subarachnoid space

CT scan:◦ Hyperdense material filling the subarachnoid

space◦ Most commonly around circle of Willlis

Things that mimic◦ pus◦ Contrast◦ Meningeal thickening secondary to meningitis

Contusional Bleed Location:

◦ Intracerebral

Patho:◦ Brain coming to a sudden stop against inner

surface of skull (contrecoup)

Common location:◦ Floor of anterior cranial fossa◦ Temporal pole

CT scan◦ Foci of hyperdensity involving grey and

white matter

Possible of progression with time

Diffuse Axonal Injuries Pathophyshio:

◦ High speed injury◦ Shearing or stretching of brain tissue

Radiography◦ May see petechial hemorrhage

Mortality◦ 30-40%

Management

Aims of ManagementGeneral aims:

1. Stabilization

2. Prevention of secondary brain injury

Specific aims:

3. Protect airway & oxygenate

4. Ventilate to normocapnia

5. Correct hypovolemia/hypotension

6. CT scan when appropriate

7. Neurosurgery if indicated

8. Intensive care for further monitoring & management

o To detect & treat immediately life threatening conditionso Idea – to keep patient alive

Primary Survey and Resuscitation

A - Airway with C-spine control

B - Breathing

C - Circulation with hemorrhage control

D- Disability

E- Exposure

A. AIRWAY AND CERVICAL SPINE

• Inadequate delivery of oxygenated blood to the brain can cause fatal

• Maintain an open airway with cervical spine control since every head injury patient must be presumed to have a spinal injury.

• The cervical spine should be immobilised initially by in-line stabilisation

• An increasing intracranial pressure produces vomiting. Protect the airway, to prevent vomiting, by gentle endotracheal intubation because an inappropriate management may precipitate dangerous increases in intracranial pressure

• Intubate - airway protection - to give controlled ventilation

INDICATIONS FOR ENDOTRACHEAL INTUBATION1. Apnoea

2. Comatose patients (GCS ≤ 8): cannot protect their airway

3. Severe maxillo-facial injury (bleeding)

4. Restless or uncooperative patients

5. Breathing is inadequate - Respiratory rate < 10 or >40. - Sa02 <90% - Excessive respiratory work. - Hypoxia Pa02<50 mm Hg with a Fi02 of 50%

B. BREATHING

• Asses patient’s breathing. - to prevent hypoxia and hypercapnia

• Identify immediately life-threatening thoracic injuries and treat them when found. (eg: tension pneumothorax)

• If the respirations are depressed, assist breathing with a bag-valve-mask or bag-valve-endotracheal tube and 100% oxygen.

C. CIRCULATION

• Normal cardiac output must be maintained - 2 large bore iv cannula

• Maintenance fluid: Dextrose solution should be avoided - Dextrose lowers plasma osmolality and increases cerebral oedema

• Intracranial bleeding will never cause hypovolemic shock

• Control bleeding by applying direct pressure. - Be sure there isn’t a depressed skull fracture beneath the wound. - In that case, apply pressure to the scalp close to the wound but beyond the fracture.

• Bradycardia , high blood pressure and slow breathing may be a sign of rising ICP (“Cushing reflex”).

D. DISABILITY

• Assess the level of consciousness using the AVPU scale

A AlertV Responds to voiceP Responds to pain

PurposefullyNon-purposefully

Withdrawal/flexor responseExtensor response

U UnresponsiveAssess pupil size, equality and reactivity

E. EXPOSURE

• Undress patient but prevent hypothermia.

• Do not miss other associated injuries.

o To detect injuries that can kill patient in few hourso Idea – to keep patient alive longer

SECONDARY SURVEY

History• Time and mechanism of injury• Circumstances of injury, e.g. accident, unexplained fall

(consider seizure or arrhythmia)• Loss or impairment of consciousness and duration• Nausea and vomiting• Clinical course prior to consultation - stable, deteriorating,

improving• Other injuries sustained• Past history of bleeding tendency

Systemic examination (Head-to-toe)Neck and cervical spine

◦ Deformity◦ Tenderness ◦ Muscle spasm

Head ◦ Scalp bruising ◦ Lacerations ◦ Swelling ◦ Tenderness ◦ Raccoon eyes* ◦ Bruising behind the ear (Battles sign)*

Eyes ◦ Pupil size ◦ Equality ◦ Reactivity ◦ Fundoscopy for retinal haemorrhage (may

indicate non-accidental injury)

Ears • Blood behind the ear drum • CSF leak

Nose • Deformity • Swelling • Bleeding • CSF leak

Mouth • Dental trauma • Soft tissue injuries

Face • Focal tenderness • Crepitus

Motor function • Reflexes present • Lateralizing sign

Precise Neurological Examination

• Level of consciousness

• Pupillary response & other cranial nerve examination

• Scalp, ears, eyes, face, jaw, mouth

• Extremity : motor & reflexes

• Signs of skull base fracture - Racoon eyes - Battle sign (8-12hours) - CSF rhinorrhoea or otorrhoea - Hemotympanum

GCS • Provide quantitative level of consciousness• The score is sensitive and reproducible indication of early

neurological deterioration

BRAINSTEM REFLEXES

1. Pupillary:a) size, b) equality and c) reflex to light

2. Gag reflex

3. Corneal reflexes

4. Doll's eye sign

Classification of Head Injury:Category Criteria

Minimal GCS= 15No loss of consciousness (LOC)No amnesia

Mild GCS=14 OR GCS 15 plus either- Brief LOC (<5min) - Impaired alertness / memory

Moderate GCS = 9-13 OR LOC ≥5min ORFocal neurologic deficit

Severe GCS = 5-8Critical GCS = 3-4

INDICATIONS FOR ADMISSION

• Altered or Deteriorating level of consciousness• Neurological symptom: (Moderate to severe headache,

vomiting > twice, giddiness )

• Cerebrospinal fluid leakage (from the ears, nose)

• Skull fracture ( x-ray & basal skull )

• Underlying medical condition (coagulation disorder)

• Prolonged post-traumatic amnesia ( > 1 hr)

INDICATIONS FOR SKULL X-RAY1. Loss of consciousness or amnesia suspected at any time2. Suspected compound fracture3. Suspected penetrating trauma4. Presence of boggy swelling particularly in the parieto-temporal region

5. Difficulty in assessing patient: alcohol intoxication, epilepsy, children

6. Suspected non-accidental injury (in children)7. CSF leak or blood from ear, nose8. Neurological symptoms or signs (headache and or vomiting more than twice)

INDICATIONS FOR IMMEDIATE CT SCAN

NICE CLINICAL GUIDELINES (2014)

• GCS less than 13 on initial assessment

• GCS less than 15 at 2 hours after the injury on assessment

• Suspected open or depressed skull fracture.

• Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign)

• Focal neurological deficit

• More than 1 episode of vomiting.

• Post-traumatic seizure.

Neurosurgical intervention:• Typically required when a significant intracranial mass lesion is present. - EDH/SDH/Parenchymal hematoma

• Craniotomy/craniectomy

• ICP monitoring

• External decompression: - Decompressive craniectomy may be performed after the removal of a hematoma such as an acute subdural hematoma.

• Internal decompression: - If the ICP exceeds 30 mmHg even after general treatment to control it or if there is clear deterioration of neurological symptoms such as a decrease in the level of consciousness, resection at the site of the brain contusion is often performed to prevent secondary brain damage

MILD/MINOR HEAD INJURY (GCS:14-15)

◦ ½-1 hourly observation◦ Ensure adequate oxygenation, ventilation & circulation◦ Discharge: if GCS improve to or remain 15◦ CT scan indication:

◦ Not improving or remain symptomatic after 6 hours observation

◦ Skull fracture esp depressed fracture◦ GCS deteriorate

Management Guideline

MODERATE HEAD INJURY (GCS: 9-13)

◦ Ensure adequate oxygenation, ventilation & circulation ( PaO2=100mmHg, PCO2=30-35mmHg)

◦ Urgent CT scan of brain ◦ Cervical spine X-ray◦ Medical / Neuro-surgical intervention◦ Admit Neuro-HDU

SEVERE HEAD INJURY (GCS : 3-8)

o Elective intubation for airway protection and ventilation

o Adequate circulation: ATLS protocols

o Blood pressure control to avoid brain oedema or hypotension

CT scan of brain & cervical

o Neuro-Surgical intervention for mass lesion associated with

neurological deficits or worsening

o ICU: Cerebral Perfusion Pressure directed therapy

o GCS=3, pupils fixed & dilated: conservative management

Take Home messages1. Loss of consciousness does not need to occur in traumatic

brain injury2. Cerebral concussion is when there is physiological

dysfunction without anatomical or radiological abnormality3. Secondary brain injury (hypoxia / hypotension eg.) can

cause more damage than primary brain injury4. Minor change in intracranial volume can raise ICP

significantly5. CPP = MAP – ICP6. Battle sign, raccoon eyes, CSF leak are features of basal skull

fracture

7. Lucid interval is an important feature of presence of extradural hemorrhage

8. Intracranial bleeding will never cause hypovolemic shock9. Never use dextrose saline as maintenance fluid10. Primary & secondary survey are the crucial part in managing

head injury11. Every head injury patient must be presumed to have a spinal

injury. 12. CT is generally the imaging study of choice in the acute

assessment of head injury13. Mass effects eg. Midline shift is an indication for

neurosurgical intervention

References• David A Olson. Head injury [internet] 2013 [updated Apr 1 2013] available from

http://emedicine.medscape.com/article/1163653• Principle and practice of Surgery 5th Edition, O. James Garden• Anderson P. Hemodynamic Complications Common in Traumatic Brain Injury.

Available at http://www.medscape.com/viewarticle/778999. Accessed March 25, 2013.

• Eisenberg HM, Gary HE Jr, Aldrich EF, et al. Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg. Nov 1990;73(5):688-98.

• Mark S. Greenberg MD, Handbook of Neurosurgery 7th edition• NICE clinical guideline 176 guidance.nice.org.uk/cg176. Triage, assessment,

investigation and early management of head injury in children, young people and adults (Issued: January 2014)

Thank You!