1. Head Injury Saurabh Sinha Department of Clinical Neurosciences Western General Hospital

3. Age Groups

4. Mechanisms of Injury

5. What now?

6. Resuscitation  Aairway with cervical spine control  Bbreathing  Ccirculation

7. Traumatic Brain Injury Immediate impact injury  Contusions and lacerations  Diffuse damage to white matter  Other types of diffuse brain injury Primary complications  Intracranial haemorrhage  Brain swelling Secondary complications  Brain damage secondary to raised ICP  Hypoxic brain damage  Infection

8. Aims  Prevent secondary brain injury  Rapid transfer to hospital

9. Brain Herniation

10. Uncal Herniation

11. Midbrain Infraction

12. Cerebral Physiology  Intracranial pressure (ICP) 0-10 mmHg  Cerebral perfusion pressure (CPP) >60 mmHg  Obligative aerobic glycolysis  Cerebral blood flow (CBF) maitained by autoregulation

13. Severe Head Injury  Raised ICP  Reduced CPP  Loss of autoregulation  Neuroexcitotoxicity

14. Raised ICP  Seizures  Brain swelling  Vasogenic oedema  Intracranial haematoma  Hypercarbia  Hypoxia

15. Neurological Assessment  Level of consciousness (GCS)  Pupillary reaction to light  Limb movements  History

16. Complicating Factors  Alcohol  Drugs  Epilepsy  Stroke  Cervical spine injury

17. The Glasgow Coma Scale and Score  Eye (1-4)  open spontaneously  open to speech  open to pain  no opening  Motor (1-6)  obeys commands  localises to pain  normal flexion  abnormal flexion  extension  no movement  Verbal (1-5)  orientated  confused  inappropriate words  incomprehensible sounds  none  GCS 3-15  Best score using upper limbs  Special cases  dysphasia  periorbital oedema  endotracheal tube/tracheostomy

18. Definition of Coma  GCS 8 or less  No eye opening  Does not speak  Does not obey commands

19. Dilated Pupil

21. Signs  Penetrating Injury  Scalp laceration or haematoma  Periorbital haematoma  Blood or CSF from nose  Blood or CSF from ear  Battle’s sign  Cranial Nerve (eye movements, facial weakness)

22. Subconjunctival Haemorrhage

23. Panda Eyes

24. Battle’s Sign

26. Indications for skull X-ray  Orientated Patients  History of LOC/amnesia  Suspected penetrating injury (?CT)  CSF/Blood from ear/nose  Scalp laceration (to bone or >5cm), bruise or swelling  Persistent headache or vomiting  Children  Fall from significant height  Onto hard surface  Tense fontanelle  Suspected NAI  Patients with impaired consciousness or neurological signs  All patients unless CT or neurosurgical transfer arranged

27. Skull Fracture

28. Depressed Skull Fracture

29. Aerocoele

30. Penetrating Injury

31. Risk of operable intracranial haematoma in head injured patients  GCS 15 (1:3615)1 in 31300  With PTA1 in 6700  Skull fracture1 in 81  Skull fracture & PTA1 in 29  GCS 9-14 (1:51)1 in 180  Skull fracture1 in 5  GCS 3-8 (1:7)1 in 27  Skull fracture1 in 4

32. Indication for urgent CT/NS referral  Coma persisting after resuscitation  Deteriorating conscious level or progressive neurological signs  Skull fracture & confusion/seizure/neuro symptoms or signs  Open injury: compound depressed #, gunshot or penetrating injury

33. Haematoma

34. Contusion

35. Multiple Contusions

36. Extradural Haematoma

37. Subdural Haematoma

38. Chronic Subdural Haematoma

39. Diffuse Axonal Injury

40. Extradural Haematoma

41. Skin Preparation

42. Craniotomy Mark

43. Opening

44. Dura

45. Subdural Haematoma

46. Subdural Collection

47. Haemostasis

48. Monitoring

49. ICP Monitoring

50. GCS Chart

51. Outcome at 1 year

52. Outcome wrt Haematoma

53. Recovery

55. Use of Helmets

56. Head Injury Management