1. MANAGEMENT OF HEAD INJURIES
KEVIN HENSHAW
BSc.(Hons.) Cert.Ed RODP

2. OBJECTIVES
TO BE AWARE OF THE PROBLEMS ASSOCIATED WITH DEALING WITH PATIENTS WITH AN ACUTE HEAD INJURY WITHIN THE PERI-OPERATIVE AREA
TO HELP MAINTAIN HOMEOSTASIS IN THE HEAD INJURED PATIENT

3. BACKGROUND Approximately 1 Million patients annually
50% of trauma-related deaths from severe head injury
1% OF ALL UK DEATHS
85% OF ALL SEVERELY HEAD INJURED PATIENTS REMAIN DISABLED AFTER 1yr
ONLY 15% RETURN TO WORK AFTER 5yrs

4. Assessment Glasgow Coma Scale (GCS) GCS 13-15 (Mild) 80%
GCS 9-12 (Moderate) 10%
GCS (Severe) 10%

5. The Glasgow Coma Scale (GCS) was developed by Teasdale and Jennett in 1974
Glasgow Coma Score The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : Best Eye Response. (4) No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously. Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated   Best Motor Response. (6) No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localising pain. Obeys Commands.

6. PATHOLOGY SCALP lacerations, contusions or abrasions CRANIUM
simple or compunded,depressed or planar, base or vault

7. PATHOLOGY UNDERLYING BRAIN Primary (result of impact)
Secondary (result of non homeostatic factors)

8. PRIMARY Intra-cranial haematoma (intracerebral,extradural or subdural)
Contusion (coup or contre-coup to impact site)
Diffuse axonal (result of mechanical shearing following deceleration)

9. NORMAL BRAIN IMAGE

10. EXTRA DURAL HAEMATOMA Extradural haemorrhage
Results from rupture of one of the meningeal arteries that run between the dura and the skull.
The middle meningeal artery is most commonly affected.
Usual cause is a skull fracture

11. ACUTE SUB DURAL HAEMATOMA
Subdural haemorrhage
More common than extradural haemorrage
Associated with sudden jarring or rotation of the head
Shears and tears the small veins which bridge the gap between the dura and cortical surface of the brain

12. TRAUMA

13. TRAUMA

14. TRAUMA

15. SECONDARY RESULT OF: Ischaemia Cerebral oedema Infection
Tonsillar or tentorial herniation
ALL EXACERBATE ORIGINAL HEAD INJURY!!!

16. INTRA CEREBRAL ABCESS

17. NORMAL AUTOREGULATION OF CBF IS LOST IN SEVERE HEAD INJURY MAKING THE INJURED BRAIN MORE SUSCEPTIBLE TO :
HYPO-OR HYPER VOLAEMIA
HYPOXIA
HYPERCAPNEA

18. INTRACRANIAL PRESSURE
MONRO-KELLIE DOCTRINE
‘CRANIUM IS CLOSED BOX’
‘Contents are incompressible, increase in one constituent or an expanding mass within the skull results in an increase in intracranial pressure’

19. FACTORS INFLUENCING OUTCOME
NORMOTENSION:
Single episode of hypotension can have catastrophic effect (systolic <90mm Hg)
Initial treatment –fluid resuscitation
Vasopressors – epinepherine
MAP of 70mm Hg

20. FACTORS INFLUENCING OUTCOME
NORMOXIA:
Hypoxemia (Spo2<90%) decreases prognosis possibly by four fold increase in mortality (Spo2<60%)
O2 maintenance needs to be balanced against any other factors egg PEEP & chest trauma

21. FACTORS INFLUENCING OUTCOME
NORMOCAPNIA:
Hyperventilation (PaCO2 <25 mm Hg) should be avoided for first 24h after Head Injury.
Hyperventilation results in vasoconstriction, reduced CBF.
First 24h CBF reduced by 50% hyperventilation may result in further cerebral ischemia

22. FACTORS INFLUENCING OUTCOME
NORMOTHERMIA:
Increased body and brain temp’ increases CBF
Cerebral metabolism and O2 utilisation
Increase in ICP

23. TRAUMA REMEMBER: AIRWAY BREATHING CIRCULATION
CERVICAL SPINE (until patient is awake treat as potentially unstable)

24. QUESTIONS