Head Injury Saurabh Sinha Department of Clinical Neurosciences Western General Hospital

Age Groups

Mechanisms of Injury

What now?

Resuscitation  Aairway with cervical spine control  Bbreathing  Ccirculation

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

Aims  Prevent secondary brain injury  Rapid transfer to hospital

Brain Herniation

Uncal Herniation

Midbrain Infraction

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

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

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

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

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

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

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

Dilated Pupil

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)

Subconjunctival Haemorrhage

Panda Eyes

Battle’s Sign

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

Skull Fracture

Depressed Skull Fracture

Aerocoele

Penetrating Injury

Risk of operable intracranial haematoma in head injured patients  GCS 15 (1:3615)1 in  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

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

Haematoma

Contusion

Multiple Contusions

Extradural Haematoma

Subdural Haematoma

Chronic Subdural Haematoma

Diffuse Axonal Injury

Extradural Haematoma

Skin Preparation

Craniotomy Mark

Opening

Dura

Subdural Haematoma

Subdural Collection

Haemostasis

Monitoring

ICP Monitoring

GCS Chart

Outcome at 1 year

Outcome wrt Haematoma

Recovery

Use of Helmets

Head Injury Management