HEAD INJURIES

Head injury occurs every 15 seconds and patients dies of head injury every 12 minutes.

Early transfer of appropriate patients and inco operation of neurosurgeons consultation is

essential. This will reduces morbidity and mortality

The Skull

• The skull is composed of the cranial vault (calvarium) and the base.

• The base of the skull is irregular and rough, allowing injury to occur as the brain

moves within the skull during acceleration and deceleration.

Skull Fracture

• Linear with no depressed skull fracture

• Depressed skull fractures

• Open skull fractures

• Basal skull fractures

The brain consists of the cerebrum, the cerebellum and brain stem.

1. The cerebrum is composed of right and left hemispheres

The left hemisphere, which usually contains the language centers, is often

referred to as the dominant hemisphere.

The frontal lobe is concerned with the emotions and motor function.

Occipital lobe with vision

The parietal lobe with sensory function

1
 The temporal lobe regulates certain memory functions but can be a relatively

silent region on the right side.

2. The brain stem consists of

• The mid- brain

• Pons and

• The medulla oblongata, which continues to form the spinal cord.

• The midbrain and the upper pons contain the retinacula activating system, which

is responsible for an awake state.

• Vital cardiopulmonary centers reside in the lower brain stem, the medulla, which

continues to form the spinal cord.

• The cerebellum controls movements, co-ordination and balance, surrounds the

pons and medulla in the posterior fossa.

Brain Injury

Alteration of consciousness is the hallmark of head injury

Increased intracranial pressure and decreased cerebral blood flow can depress the level of

consciousness.

Glasgow coma scale (GCS) provides a quantitative measure of the patient’s level of

consciousness. The GCS is the sum of scores for three areas of assessment

– Eye opening

– Verbal response

– Best motor response

Each graded separately

2
Eye Opening

• Spontaneous already open with blinking (normal) E =4 points

• To speech not necessarily to request for eye opening E=3 point

• To pain stimulus should not be applied to the face E=2 points

• None: E =1 point

Verbal Response

• Orientation- knows name, age etc. V=5 points

• Confused conversation- still answers questions V= 4 points

• Inappropriate words- speech is either exclamatory or random, but recognizable

words are produced V= 3 points

• Incomprehensible sounds- grunts and groans are produced but no actual words are

uttered. Do not confuse with partial respiratory obstruction V =2 points

• None V= 1 point

Best Motor Response

• Obeys commands M=6 points

• Localized pain M =5 points

• Withdraws- pulls away from painful stimulus M=4 points

• Abnormal flexion- decorticate posture M =3 points

• Extension response – decerebrate posture M =2 points

• No movement M- 1 point

Glasgow coma scale can be used to categorize patients.

3
 • A patient in coma is defined as having GCS of 8 points are in coma.

• Those with more than 8 points are not in coma.

Diffuse Brain Injuries

1. Concussion:- a brain injury followed by a brief loss of neurological functions

2. Diffuse axonal injury: coma often lasting for days or weeks. It does not require

surgery

3. Contusion, Hematomas and Hemorrhage brain injuries may require emergency

surgery

Raised Intracranial Pressure

• The intracranial pressure is described as a relationship among volumes of CSF,

blood and brain

• Brain volume is relatively static except when cerebral edema occurs

• A small increase in intracranial mass volume causes very large increase in

intracranial pressure resulting in decrease of cerebral perfusion pressure.

EMERGENCY MANAGEMENT OF HEAD INJURY

Establish a specific diagnosis

– Need for surgery

– Diagnostic triage

Emergency management

4
Aim at Maintaining cerebral metabolic needs- supply oxygen plus glucose to the brain

Treat intracranial hypertension

Fluid management and to prevent edema

Diuretics= Manitol and furosemide

When seeking neurosurgical consultation you must relay the following patient

information:-

• Age of the patient

• Mechanism of injury

• Respiratory and cardiovascular status

• Results and neurological examination especially the level of consciousness,

pupillary reaction and presence of lateralized extremity weakness

• Presence and type of cerebral injuries

• The results of diagnostic studies if obtained