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    6.head Injury

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    jitendra magar
    Head trauma accounts for 1/3-1/2 of trauma deaths. Good outcomes are possible without neurosurgeons or CT scans if the focus is on preventing further brain injury by maintaining airway, breathing, circulation (ABC), and avoiding increases in intracranial pressure (ICP). Key priorities include monitoring for neurological deterioration, signs of elevated ICP like unequal or dilated pupils, and treating hypotension, as secondary brain injury can be prevented. Acute extradural and subdural haematomas may require surgical drainage if detected.

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    6.head Injury

    Uploaded by

    jitendra magar
    37 views37 pages
    Head trauma accounts for 1/3-1/2 of trauma deaths. Good outcomes are possible without neurosurgeons or CT scans if the focus is on preventing further brain injury by maintaining airway, breathing, circulation (ABC), and avoiding increases in intracranial pressure (ICP). Key priorities include monitoring for neurological deterioration, signs of elevated ICP like unequal or dilated pupils, and treating hypotension, as secondary brain injury can be prevented. Acute extradural and subdural haematomas may require surgical drainage if detected.

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    6.Head_injury

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    Head trauma accounts for 1/3-1/2 of trauma deaths. Good outcomes are possible without neurosurgeons or CT scans if the focus is on preventing further brain injury by maintaining airway, breathing, circulation (ABC), and avoiding increases in intracranial pressure (ICP). Key priorities include monitoring for neurological deterioration, signs of elevated ICP like unequal or dilated pupils, and treating hypotension, as secondary brain injury can be prevented. Acute extradural and subdural haematomas may require surgical drainage if detected.

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    37 views37 pages

    6.head Injury

    Uploaded by

    jitendra magar
    Head trauma accounts for 1/3-1/2 of trauma deaths. Good outcomes are possible without neurosurgeons or CT scans if the focus is on preventing further brain injury by maintaining airway, breathing, circulation (ABC), and avoiding increases in intracranial pressure (ICP). Key priorities include monitoring for neurological deterioration, signs of elevated ICP like unequal or dilated pupils, and treating hypotension, as secondary brain injury can be prevented. Acute extradural and subdural haematomas may require surgical drainage if detected.

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    HEAD TRAUMA

    HEAD TRAUMA

    • Accounts for 1/3-1/2 of trauma deaths


    • Good outcomes are possible without neurosurgeons and CT
    scans
    • Aim to prevent further injury to the brain

    REMEMBER ABC
    How would you manage this patient?
    You don’t need to be a neurosurgeon

    ABC
    Hypoxia (A,B) & Hypotension (C) are Horrible
    in Head-Injured patients
    ANATOMY

    • Scalp
    • Skull
    • Meninges
    • Brain
    • CSF
    • Blood Supply
    NORMAL BRAIN PHYSIOLOGY

    • High oxygen and glucose requirements


    • Depends on constant blood flow
    • Ischaemic time for brain is a few minutes only
    CEREBRAL OXYGEN DELIVERY

    • Depends on:
    • Oxygen content in blood
    • Cerebral blood flow (CBF)

    • CBF mainly depends on balance between MABP and intracranial


    pressure (ICP)
    INTRACRANIAL PRESSURE

    • Increased ICP
    • Haematoma
    • Brain swelling
    •  pO2
    •  pCO2
    •  blood flow from brain (straining, coughing etc)

    • All these things will  ICP and  CBF


    Intracranial Pressure
    PATHOPHYSIOLOGY
    • Primary Injury
    • Occurs at time of injury

    • Secondary Injury
    • Occurs after injury
    • May be preventable
    PRIMARY INJURY
     Diffuse axonal injury
     acceleration
     deceleration
     Cerebral contusion
     Penetrating injury
    SECONDARY INJURY
    • Hypoxia
    • Hypoperfusion (MAP, ICP)
    • Hypoglycaemia
    • Fever, seizures
    • Both increase brain’s metabolic requirements
    INITIAL ASSESSMENT

    Airway (+ C-spine)
    Breathing
    Circulation
    Disability (AVPU, pupils)
    Exposure
    NEUROLOGICAL EXAMINATION

    • Level of consciousness
    • AVPU
    • Glasgow Coma Score
    • Pupils
    • Size, response to light
    • Motor weakness
    • Posture, tone, reflexes
    NEUROLOGICAL EXAMINATION

    • Other examination
    • Lacerations, bruising, bony irregularity
    • Eyes – fundi, corneal reflex
    • Tympanic membranes
    • Respiratory pattern
    GLASGOW COMA SCORE

    • Grades severity of head injury


    • Score out of 15
    • Subject to inter-observer variation
    • Trend of GCS over time very useful
    • Important to also describe responses
    GLASGOW COMA SCORE
    EYE OPENING

    Open spontaneously 4
    Open to command 3
    Open to pain 2
    None 1
    GLASGOW COMA SCORE
    BEST VERBAL RESPONSE

    Oriented 5
    Confused 4
    Inappropriate words 3
    Inappropriate sounds 2
    None 1
    GLASGOW COMA SCORE
    BEST MOTOR RESPONSE

    Obeys command 6
    Localises to pain 5
    Withdraws to pain 4
    Abnormal flexion 3
    Extensor response 2
    None 1
    GLASGOW COMA SCORE
    SEVERITY OF HEAD INJURY

    Severe GCS < 8

    Moderate GCS 9-12

    Minor GCS 13-15


    PUPILLARY SIGNS

    • Size

    • Equality

    • Reactivity
    PUPILLARY RESPONSES

    Fixed, dilated, • Severe hypoxia


    unresponsive • Hypothermia

    • Seizures
    PUPILLARY RESPONSES

    Unilateral, dilated, • Expanding ipsilateral


    unresponsive lesion (eg extradural)
    • Brain herniation

    • Seizures
    ACUTE EXTRADURAL
    ACUTE SUBDURAL

    • Potentially life-threatening
    • Immediate recognition essential
    • Require burr-hole decompression
    • Difficult to treat in district hospitals
    Extradural Haematoma
    ACUTE EXTRADURAL
    CLASSICAL FEATURES

    • LOC  lucid interval  deterioration


    • middle meningeal artery bleed
    • overlying skull fracture
    • contralateral hemiparesis
    • ipsilateral fixed pupil
    Acute Subdural Haematoma
    ACUTE SUBDURAL

    • Tearing of bridging vein between cortex and dura


    • Severe contusion of underlying brain
    • Worse prognosis than extradural haematoma
    • Usually no lucid interval
    OTHER INJURIES

    Usually do not require neurosurgery

    • Base-of-skull fractures
    • Cerebral concussion
    • Depressed skull fracture
    • Intracerebral haematoma
    Battle’s Sign
    Racoon Eyes
    MANAGEMENT
    OF HEAD TRAUMA

    AIRWAY (and C-spine)


    BREATHING
    CIRCULATION
    +
    AVOID  ICP

    AIM TO PREVENT SECONDARY INJURY


    SEVERE HEAD INJURY MANAGEMENT

    • Intubate

    • Moderate hyperventilation

    • Treat hypotension

    • Sedation +/- paralysis


    SEVERE HEAD INJURY MANAGEMENT

    • Nurse head up 20o

    • Prevent hyperthermia

    • Complete secondary survey

    • Reassess frequently
    BEWARE

    • Deteriorating conscious state


    • Penetrating injury
    • Focal neurological signs
    - unequal, dilated pupils
    - one-sided weakness
    - seizures
    - posturing
    IMPORTANT POINTS

    • ABCs
    • Prevent secondary injury
    • Isolated head trauma doesn’t cause hypotension
    • Look for other injuries
    • Deterioration  reassess
    Summary

    • A, B, C first
    • Prevent  ICP
    • Monitor neurological signs and ABCs
    • Acute extradural and subdural haematomas require surgical
    drainage

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