1. HEAD INJURY

2. OUTLINE INTRODUCTION RELEVANT ANATOMY MECHANISMS EPIDEMIOLOGY
AETIOLOGY
CLASSIFICATION
TYPES
CLINICAL PRESENTATION
Raised Intracranial Pressure
MANAGEMENT
COMPLICATIONS
CONCLUSION

3. INTRODUCTION
Damage to the brain and/or its coverings due to the application of an external force.
Also called CRANIOCEREBRAL INJURY

4. RELEVANT ANATOMY The brain is covered by The meninges- 3 layers
The skull- 2 “
The scalp- 5 “

5. RELEVANT ANATOMY

6. MECHANISMS Could be Closed injury: Penetrating injury: Blunt Crushing
Bullet or missile
Sharp or non-missile

7. EPIDEMIOLOGY
Age, sex and geographical location are important epidemiological factors.
Less common in extremes of ages
M>F
Commoner in urban areas.

8. AETIOLOGY RTA Falls Recreational e.g Boxing, American football Assault
Battered child syndrome
Penetrating injury e.g gunshot, javelin
Blast injury

9. CLASSIFICATION Based on Glasgow Coma Score Open or closed
Mild
Moderate
Severe </=8
Open or closed
Primary or secondary
Scalp, skull or brain

10. PATHOPHYSIOLOGY
COUP: An injury occurring directly beneath the skull at the area of impact.
CONTRE COUP: injury remote from the site of trauma

11. TYPES SCALP INJURY: Could be And could be intact. Abrasions
Lacerations
Haematomata
Subcutaneous
Subaponeurotic
Subperiosteal
And could be intact.

12. TYPES SKULL INJURY FRACTURE COULD BE Linear Depressed Basal
Diagnosis is clinical

13. TYPES
BRAIN INJURY: Could be
Primary
Secondary

14. Primary brain injury Occurs at time of trauma May be
Localised e.g. contusion and laceration or
Generalized e.g. concussion or nerve fibre shearing

15. Secondary brain injury
Occurs from brain compression by
Haematoma
Oedema
Infection
Hypoxia
Electrolyte derangements

16. Extradural haematoma Usually occurs in temporal region Sometimes in
Frontal region
Parietal region
Posterior cranial fossa
Clinical features are
Mild/severe injury
LOC
Skull fracture(rare in children)
Worsening from cerebral hemisphere compression

17. Extradural haematoma (cont'd)
Deteriorating level of consciousness
Restlessness associated with drowsiness
Headaches
Pupillary dilatation on the side of the haematoma
Rising B.P.
Falling R.R and P.R
If it continues
Contralateral long tract sign
History is short occurring within 24 hours of injury

18. Extradural haematoma

19. Subdural haematoma 4 Clinical types
Acute type: occurs within 48hrs & follows severe head injury. Px is unconscious from the time of the accident and further deteriorates.
Subacute :occurs between 2-14 days following injury. Px fails to improve and may develop s&s of cerebral compression. Exploratory parietal or frontal Burr holes for diagnosis and drainage.

20. Subdural haematoma (cont'd)
Chronic: injury may be trivial; or from hemorrhage in tumours, rupture of an aneurysm or angioma. Also haemoglobinopathy and anticoagulant tx. It inreases in size by further repeated haemorrhagesand osmotic effect of blood and its breakdown products., forming an outer and inner membranes which are fragile and bleed easily.
Infantile: in</=2yrs, usually a hygroma, and may be caused by birth trauma. Fx is big head syndrome

21. Subdural haematoma

22. CLINICAL PRESENTATION
Varies:
Headache
Fx’s of SOL
Fluctuating level of consciousness.
Mental changes
Lateralizing signs:
CNIII palsy,
Supranuclear facial palsy
Jacksonian epilepsy
Hemiparesis

23. RAISED INTRACRANIAL PRESSURE
As the SOL increases in volume
Compensatory displacement of blood and CSF prevent intracranial pressure from rising
Mechanism soon fails
Brain is displaced through the foramen magnum or tentorial hiatus (herniation/coning)
This soon fails and ICP rises above the BP and brain perfusion decreases
Irreversible brain damage and brain oedema.
Thus mgt must be prompt

24. Medical mgt
-position head up 30
-Avoid obstruction of venous drainage from the head
-Normocarpnia kpa
-Diuretics: furosemide,mannitol
-Seizure control
-Normothermia
-Fluid and electrolyte balance

25. Surgical mgt
-early evacuation of focal hematomas EDH,ASDH
-CSF drainage via a ventriculostomy
-delayed evacuation of swelling contusions
Decompressive craniectomy

26. MANAGEMENT FIRST AID AND RESUSCITATION INITIAL ASSESSMENT HISTORY
EXAMINATION
INVESTIGATIONS
TREATMENT
REHABILITATION

27. MANAGEMENT (cont'd) Initial assessment History
For other causes of loss of consciousness if no evidence of injury and there is loss of consciousness
Alcoholic intoxication
Post-epileptic stupor
CVA
Hyper/Hypoglycemic coma
Uremia/hepatic failure
History
From eye witness if loss of consciousness(LOC), when, how
If conscious, any gap in memory,-retrograde or post traumatic amnesia

28. MANAGEMENT (cont'd) Examination
GPE: examine the scalp, skull, pallor, jaundice, mouth odour,
Vital signs
Ear, nose for CSF or Blood
GCS
CNS:
Pupils: to diagnose SOL
Lateralizing signs
Others
Other associated injuries
Spinal
Chest
Abdomen

29. MANAGEMENT (cont'd) Investigations Baseline: FBC, E, U & Cr
Skull x-ray
Echoencephalography
CT/MRI
Brain scan
Exploratory Burr-hole

30. TREATMENT Depends on severity of injury and clinical course
In minor trauma, with no history of LOC, lateralizing sign, pupillary changes, vital signs’ abnormality, observe and send home after 24 hours.
If otherwise, and deteriorating, urgent exploratory burr hole and if no hematoma collection, investigate further.
Continue to assess the GCS

31. Non operative management
Admit the patient with severe head injury into ICU
Nurse them in head up position 30-45
Avoid drugs that will depress the nervous system
Regular monitoring of neurovital signs(temp,bp,pr,gcs,pupillary shape,size and reaction,evidence of raised ICP.

32. Do not restrict fluid
Give analgesics but not too potent analgesics
Input and output monitoring chart
Correct anaemia if any
Open wound and give TT prophylaxis
+/-antibiotics
Protect the spine
Do not administer steroid

33. TREATMENT (cont'd) The unconscious patient:
Maintain airway
Skin care
Catheterization
Feeding
Drugs
Early physiotherapy
Scalp injuries: may be a guide to the side of hematoma
Lacerations
Haematoma

34. TREATMENT (cont'd) Skull fractures Linear fractures of the vault
Depressed fractures
Closed
Indications for elevation of closed depressed fracture
Open depressed fracture: must be operated within 24hrs
Fracture of the base of the skull.

35. TREATMENT (cont'd) Extradural haematoma: Subdural hematoma:
Requires early exploratory Burr holes
If it is to be delayed, give Mannitol infusion
Procedure
Subdural hematoma:
Acute
Subacute
Chronic
Infantile

36. REHABILITATION Multidisciplinary: Neurosurgeon Neurologist
Psychiatrist
Psychologist
Orthopaedic surgeon
Physiotherapist
Speech therapist
Occupational therapist
Vocational therapist
Social worker

37. COMPLICATIONS Cerebral oedema Meningitis Cerebral abscess
Cranial nerve injuries
Subarachnoid and intracerebral hemorrhage
Post traumatic epilepsy
Metabolic disorder
Fat embolism
Carotico-cavernous aneurysm
Headache
Post-concussional syndrome
Death

38. CONCLUSION Prompt intervention High index of suspicion
Adequate history
Thorough examination
Relevant investigations
Goal oriented treatment
are the essential tools to ensure good outcome in established cases of head injury.

39. thanks