1. Evaluation & management of head injured patient

2. Classification of Head Injuries
blunt and penetrating injury
closed and open head injury
Or neurologically speaking
closed or blunt inj. can be classified
Concussion
Contusion
Laceration
Diffuse axonal injury

4. MECHANISMS OF INJURY inertial or contact mechanisms
Inertial injuries are commonly called "acceleration" or "deceleration" injuries
Contact injuries are commonly called coup & contercoup injuries.

5. MECHANISMS OF INJURY
The brain is damaged by one or both of two mechanisms:
(1) through strains produced within the brain tissue itself and
(2) through differential movements between the brain and the skull.
Contact injuries occur both at the site and remote from the point of impact on the head and result in skull fractures and contusions.

6. Penetrating Injuries
Gunshot wounds to the head are a major cause of morbidity and mortality in large urban areas
bullets can cause damage to brain parenchyma through three mechanisms:
(1) laceration and crushing;
(2) cavitation; and
(3) shock waves.

7. Secondary Brain Damage
SYSTEMIC INSULTS
5 Hs
Hypoxia
Hypotension
Hypercapnia
Hyperthermia
Hyperglycemia and hypoglycemia

8. Traumatic Unconsciousness
"Coma" is applied to more profound impairment of consciousness, defined many years ago by the Head Injury Committee of the World Federation of Neurosurgical Societies as "an unrousable, unresponsive state, regardless of duration; eyes continuously closed.
There is now no merit in continuing to use terms to qualify the depth of coma (e.g., "light," "semi coma") or terms such as "drowsy" or "stupor,"

9. How to evaluate the patient
The evaluation depend mainly on 2 things
The Glasgow coma scale
The examination of pupil

10. 1 2 3 4 5 6 GCS none Best motor response Verbal response Eye opening
Extention to pain
Flexion to pain
Withdrawal to pain
Localize the pain
Obey command
Best motor response
Incomprehensible sound
Inappropriate word
confused
oriented
Verbal response
To pain
To verbal
Spontaneous
Eye opening

11. a severe head injury = A Glasgow Coma Scale score of 8 or less at the time of admission
A moderate head injury = A Glasgow Coma Scale score of 9-12
A minor head injury = A Glasgow Coma Scale score of 13-14

12. Pupil examination E.R.T.L. IN Equality
☼☼The triad of a deteriorating level of consciousness, pupillary dilatation, and an associated hemiparesis = highly suggestive of a hemispheric mass lesion causing transtentorial herniation

13. Pathology and Pathophysiology of Head Injury
DAMAGE TO THE SCALP
SKULL FRACTURES
Basilar Skull Fractures
Vault skull fractures
Linear
Sutures diastasis
Depressed Fracture
Traumatic Hematomas
Brain Stem Trauma
Cranial Nerve Injuries

14. DAMAGE TO THE SCALP

16. BRAIN SWELLING
Intracellular (cytotoxic)
Extracellular (vasogenic)

17. Diagnosis and Treatment of Moderate and Severe Head Injuries
PREHOSPITAL CARE
ABCs S = Sugar
securing the patient's airway, A
ensuring adequate oxygenation, B
initiating fluid resuscitation, C
stabilizing the cervical and thoracolumbar spine,
identifying and stabilizing extracranial injuries,
and assessing the patient's level of consciousness.
Obtaining information on the mechanism of injury and

18. IN-HOSPITAL RESUSCITATION AND EVALUATION
Hypoxia and Airway Management(Specific indications for intubation)
Hypotension and Fluid Resuscitation (systolic blood pressure of less than 90 mm Hg was associated with an increase in mortality of 85 per cent.)
►►irreversible brain stem failure

19. Fluid Resuscitation Ringer's lactate solution normal saline
273 mOsm per kg mOsm per kg
Recently, hypertonic saline 7.5% + Dextran
3 per cent saline was associated with normal intracranial pressure
☺☻no significant difference in outcome has been seen when comparing clinical series of colloid versus isotonic crystalloid fluid resuscitation.

20. Up to date
►► Rapid infusion of 1 to 2 L of 0.9 per cent isotonic saline is generally effective in hemodynamically stabilizing most trauma victims.
►► combination of normal saline and colloid (5 per cent albumin) in a three-to-one or four-to-one ratio when rapid, high-volume resuscitation is required.

21. History & examination
In the moderate or severely injured patient (Glasgow Coma Scale of 13 or less),
History
examination
level of consciousness,
the pupillary light reflexes,
extraocular eye movements,
lower brain stem reflexes for patients in deep coma, and
the motor examination.

22. Skull Radiography SXR

24. Skull Radiography CT

27. Magnetic Resonance Imaging

31. Herniation syndromes