Hugo Poncia

Head Trauma Epidemiology Physiology History Examination Investigations Treatments Cases

Introduction 165,000/year in UK Mean age % all trauma deaths are caused by Head injury Commonest cause of life-long disability 15,000 are moderate or severe 7.5% death, 20% disability

Brain Injury PRIMARYPRIMARY injury: Shearing, Diffuse axonal injury, Contusion, Haemorrhage, Laceration. SECONDARYSECONDARY injury: Cerebral oedema, Hypoxia, Hypercapnia, intracranial Haemorrhage, Increased ICP, Hypotension, reduced CBF, infection, Epilepsy.

Potentially avoidable deaths are often the result of delayed, inappropriate or inadequate treatment of secondary brain damage.

Physiology Monro-Kellie doctrine CPP= MAP- ICP Normal ICP 8-15 mmHG Small changes in volume can result in big increases in ICP Venous Arterial Brain Mass CSF volume volume

Physiology Autoregulation limits mmHG CPP >70 is ideal Normal CBF 50ml/100g brain/min If > 130mmHg Oedema 50% of severe head injuries (GCS 20

Intracranial Haematoma Extradural Intradural »Subdural »Intracerebral Subarrachnoid Mixed

Extradural Epidemiology: All ages but more common if <40yrs and males The most common site in children Symptoms and signs: Lucid period. Pupils dilate late. 75% have skull # Prognosis: 10% mortality usually due to diffuse axonal injury

Acute Subdural Epidemiology Mostly over 40yrs with significant trauma Small brains, coagulopathies, 3 days from injury Types Diffuse, multiple collections (more common) One big bleed Usually associated with axonal injury Prognosis-30% mortality

Subacute and Chronic Subdural Frequently no history of trauma Present as raised ICP, sometimes weeks after cause Associated with underlying brain trauma. Frequently (approx 20%) recollect (osmotic/rebleed)

Traumatic Subarrachnoid Not raised ICP, presents like ordinary SAH Which came first the accident or the headache? If in doubt - needs arteriography to exclude aneurysm Nimodipine and hydration are effective Prognosis better than aneuysmal SAH

Intracerebral Haematoma Cerebral contusions and haematomas are different Treatment may involve surgery if Signs of raised ICP CT suggests that raised ICP will develop! Posterior fossa bleeds Otherwise treat as diffuse injury

History Mechanism Baseline GCS AMPLE Alcohol, Diabetes, Anticoagulants Symptoms: Nausea, Vomiting, Headache, Visual Symptoms, Fits, Amnesia.

Criteria for admission Skull fracture Persistent GCS < 15 Persistent vomiting Epileptic fit Abnormal neurological signs Mastoid bruising Orbital bruising Lack of supervision at home IF IN DOUBT ADMIT!

Beware the drunk head injury!

Examination AVPU or GCS Pupillary response Examine for Basal skull # Depressed skull #- explore scalp wounds Lateralising weakness, tendon reflexes, plantars, sacral sensation

Examination- Basal Skull # Raccoon Eyes Scleral haemorrhage without posterior limit Haemotympanum, rhinorrhoea & otorrhoea Battles sign- bruising over mastoid (intracranial air, opaque sphenoid sinus)

Neuro obs Record neuro-observations half hourly GCS Pupillary size (mm) and reactivity Respiratory rate Pulse rate Blood pressure Limb power

GCS Minor GCS 13-15…… per Moderate GCS 9-12 ……...18 per 100,000 Severe GCS <8…... ……...8 per 100,000 Deteriorating GCS is hallmark of secondary brain injury…….. RE-ASSESS

GCS- Eyes Best response Supra-orbital stimulus E 4 Spontaneous E 3 Speech E 2 Pain E 1 None

GCS- Motor M 6 Commands M 5 Localises M 4 Withdraws M 3 Abnormal Flexion M 2 Extends M 1 None

GCS - Verbal V 5 Orientated V 4 Confused V 3 Inappropriate words V 2 Incomprehensible sounds V 1 None

Risks of Intracranial Haematoma GCS 15 no # 1:5983 Confused no skull # 1:121 Fully orientated with skull # 1:32 Confused with skull # 1:4

A fully conscious patient (GCS 15) with a skull fracture has a 1 in 30 chance of harbouring an intracranial haematoma.

A patient who is not fully conscious with a skull fracture has a 1 in 4 chance of harbouring an intracranial haematoma

Investigation Blood glucose ABG Clotting G&S / X-match CT DPL?

Indications for SXR? Loss of consciousness Post traumatic amnesia Scalp damage GCS < 15 Abnormal neurological signs Vomiting

Criteria for CT Scan? GCS < 15 + skull # Abnormal neurology + skull # Fit + skull # Developing neurological signs without coma Fall in GCS with normal BP and pO2 GCS 8 hours Persistent vomiting

Treating shock and hypoxia takes precedence over moving or CT scanning the patient.

Treatment ABCABC INTUBATION?…What are the indications? GCS<8 Loss of laryngeal reflexes Inadequate ventilation (pO2 6Kpa) Respiratory arrhythmia Reduce ICP by hypocarbia pCO2<3.5Kpa

Avoid BVM with basal skull # Rapid sequence induction..c-spine injury? Paralysis Sedation..propofol? Orogastric tube Talk to neurosurgeon early

C Cautious fluid replacement Avoid hypo-osmolar fluids Treat hypovoalemia/shock aggressively Avoid Internal jugular lines Urinary catheter/ Arterial line Abdominal/Pelvic injury? Bolt?

Treatments Resuscitation..Resuscitation.. THINK ABC Consider early ventilation Treat space occupying lesions with surgery Treat Fits »Diazepam »Phenytoin ( 5-10mg/kg at 50mg/min) »Thiopentone infusion Mannitol? 0.5-1g/kg over mins Good secondary survey

Post head injury syndrome

Mannitol Buys time Osmotic gradient between plasma /brain 1g/Kg (5ml/Kg) 0.5g/100mls of 20% over 15mins 50ml aliquots of 20% over 10 mins Equilibration, fully osmolised at 310 mOSM, don’t give if >320 May cause ATN, Hypertension & high intracellular osmotic pressure, phlebitis

From the following list which patients need to be admitted?: A 25 year old with a parietal skull fracture. A 43 year old who keeps on asking what happened. A fully alert 37 year old with an aortic valve replacement and normal skull X-ray. A 19 year old student who lives in a bed sitter.

Which of the following would you X-ray? A 3 month old baby who has "rolled off a couch". An 18 month old who has run into a door sustaining a large right sided forehead swelling. An 18 year old struck over the head with a billiard cue. A 25 year old in a 3 metre fall from scaffolding. A 43 year old intoxicated man who had fallen backwards from a bar stool onto a concrete floor. A 72 year old who struck her head on an open cupboard door.

That’s all folks