HEAD TRAUMA

Drs. Afnan abdirahman

MBBS Elrazi University
General surgery resident(UOH/IMU)
◦ Initial approach.
◦ General management
◦ Specific injuries
◦ A. scalp laceration
◦ B. skull fracture
◦ C. concussion
◦ D. diffuse axonal injury
◦ E. cerebral contusion
◦ F. epidural hematoma
◦ G. subdural hematoma
◦ Subarchniod hematoma.
◦ It is the most common cause of death in young adults (age 15–24 years) and is more
common in males than females
◦ Brain oxygen consumption is about 3.5 ml 100 g–1 min–1. The brain relies on blood-
borne glucose for 90% of its energy requirements.
◦ Normal cerebral blood flow is approximately 55 ml 100 g–1 min–1 and is usually
maintained at a constant level via mechanisms termed cerebral autoregulation.
◦ Head injury associated with traumatic brain injury (TBI) occurs with an incidence of 20–
40 cases per 100 000 population per year.
Traumatic brain injury(TBI)
◦Is a nondegenarative , noncongenital insult to
the brain from an external mechanical force,
possible leading to permanent or temporary
impairement of cognitive, physical, and
psychosocial function, with an associated
diminished or altered state of conciousness.
◦ Layers of the scalp is . Skin, Connective tissue, Aponeurosis, Loose
areolar tissue, Periosteum.
◦ Monroe Kellie hypothesis volume within the skull remains constant
◦ CPP= MAP- ICP
◦ Reduced CPP is the pathological force of concern during head
injury. Bleeding within skull raises the ICP. Body will compromise by
raising the MAP.
◦ Cushing response seen in elevated ICP, hypertension,
bradycardia, and tachypnea.
Initial approach
◦ All head injury are a C-spine injury until proven otherwise
◦ A. ensure secure airway. Hypoxia is an independent risk factor for mortality.
◦ All patient should be put on 100% high flow oxygen
◦ Patient with GCS <8 should be intubated via orotracheal intubation.
◦ B. all patient should be monitored with pulse oximetry and frequent checks of respiratory
status
◦ Patient who are intubated should be on ABG.
◦ C. Maintain MAP>90mmHg with fluids. Hypotension is an indication risk factor for mortality
and morbidity
◦ Avoid glucose contain fluids.
◦ Watch carefully for Cushing response( BP, HR RR )
◦ D. obtain GCS score on the pt. this will help categorize the head injury.
◦ If the patient have altered mental status check for possible reversible causes.
◦ Reversible causes canbe remembered by how they are treated
◦ Hypoglycemia; give dextrose
◦ Hypoxemic; give 100% oxygen
◦ Pinpoint pupil; nalxone
◦ Alcohol; thaimine with fluid
◦ • minor head injury: GCS 15 with no loss of consciousness(LOC);

◦ • mild head injury: GCS 14 or 15 with LOC;

◦ • moderate head injury: GCS 9–13;

◦ • severe head injury: GCS 3–8.

◦ Blunt vs. penetrating
◦ Head injury may be classified as blunt or penetrating.
◦ Penetrating head injuries are further divided into low-velocity injuries such as those
caused by stabbing and high-velocity injuries such as gun- shot injuries.
◦ Skull fractures may be divided into vault or base of skull fractures.
◦ Vault fractures may be open or closed, linear or comminuted, depressed or non-
depressed.
◦ Base of skull fractures may or may not be associated with CSF rhinorrhoea and
otorrhoea or cranial nerve palsy.
CLINICAL FEATURES.
History
◦ History should begin with the mechanism of injury. A dangerous mechanism of injury
such as a fall from a height or a high-speed motor vehicle accident should make you
suspicious of multisystem injury, including spinal injury
◦ A head injury with LOC when there is no clear accidental mechanism of injury should
prompt you to think of non-accidental causes of collapse, such as syncope or
aneurysmal subarachnoid haemorrhage, or medical conditions, such as
hypoglycaemia
◦ Try to establish the neurological status of the patient at the time of the injury and soon
afterwards
◦ Is there a history of LOC or amnesia? Amnesia may be antegrade or retrograde
◦ Was the patient responding, moving and talking appropriately after the incident?
◦ Was there evidence of seizure activity?
◦ in the severely head-injured patient, what was the GCS at the scene, prior to intubation
or on arrival at hospital?
◦ Have there been any abnormalities of pupillary responses?
◦ Is there a history of possible hypoxia or cardiovascular instability?
◦ Taking a history in head injury
◦ Mechanism of injury
◦ Loss of consciousness or amnesia
◦ Level of consciousness at scene and on transfer
◦ Evidence of seizures
◦ Probable hypoxia or hypotension
◦ Pre-existing medical conditions
◦ Medications (especially anticoagulants)
◦ Illicit drugs and alcohol
Examination
◦ Examination should begin with resuscitation and a primary survey.
◦ The cervical spine should be immobilised with three-point fixation.
◦ ‘D’ in the ABCDE approach to a primary survey stands for disability and should include
assessment of pupillary size and reactivity, GCS and the presence of focal neurological
signs.
◦ A full head, neck and peripheral nerve examination is performed as part of the
secondary survey.
◦ Neurological examination should be repeated frequently and recorded, as changes in
neurological status imply alterations in ICP and changes in the GCS are much more
important indicators of the need for treatment than any absolute level.
◦ the best possible score is 15/15 and the worst possible score is 3/15.
◦ Secondary survey in a head-injured patient also includes a detailed examination of the
head, face and neck.
◦ First, look and feel the scalp. There may be evidence of external head injury such as
subgaleal hematoma or scalp laceration, which may be a cause of significant external
blood loss.
◦ Palpation of a scalp laceration may reveal an underlying skull fracture with or without a
CSF leak.
◦ Look for clinical evidence of skull base fracture: bilateral periorbital bruising (raccoon
eyes), Battle’s sign (bruising over the mastoid)
Raccon eye. Battle sign
◦ Bleeding from an ear may result from local trauma or from a skull base fracture with a
perforated tympanum.
◦ A skull base fracture may be associated with a facial or vestibulo- cochlear cranial
nerve injury.
◦ Examine the eyes. Look for evidence of injury to the conjunctiva or cornea. Re-
examine the pupils. Using an ophthalmoscope.
◦ Assess the facial skeleton for evidence of orbital ridge, zygomatic or maxillary fractures.
◦ A peripheral nerve examination should record limb tone, evidence of motor weakness
or sensory loss, and reflexes.
◦
General management
◦ After intial assesment, head CT scan is warranted in all but the very few head injury pts.
◦ Indications of CT scan include
a) Loss of consciousness
b) Neurological deficit
c) Suspected skull fracture on palpation.
◦ Lab request also CBC, Blood type, Blood alcohol level, toxicology
◦ Don’t remove any impaled object until pts is in the OR.
Specific injuries: soft tissue and bone
injuries
◦ Scalp laceration:
◦ scalp bleed profusely, it can appear with skull fracture or with out then you have to
consider CT if any doubt.
◦ Tx can be treated with staples or simple interrupted suture; make sure there is no other
injury.
◦ Skull fracture:
◦ Get CT if suspected on examination, and to determine the type of fracture.
◦ Types o skull fracture:
a) Closed fracture: often associated with more serious intracranial problems. Which will
show up on CT. and this type need no specific tx
b) Depressed fracture: increased risk of post traumatic seizure and infection must go to
the OR.
c) Open fracture: often associated with scalp laceration and palpable. Increased risk
of infection. Must go to the OR
d) Bassilar fracture: associated with racoon eye, battle sign, ecchymosis, otorrhea,
rhinorrhea, hearing loss.
Diffuse intracranial injuries
◦ Concussion:
◦ It is minor diffuse injury causing transient confusion or altered mental status secondary
to acute truama. Thought to be due to impairment of the reticular activating system.
◦ They are mild may present with headache, followed by resolution.
◦ Primary concern is a concurrent, more severe underlying intracranial
disorder(hematoma )
◦ Following suspected concussion. CT scan is indicated if GCS <14 after 2 hours, or if GCS
was ever <13.
Cerebral contusion
◦ Diagnosed on CT.
◦ A bruise of the brain tissue, caused by either direct or indirect from a blow to the head.
◦ When direct caused by a blow, the brain is injuried at the site of the injury this is know as
a coup injury. If the opposite side is injuried it is know us contra-coup injury. And both of
this can be present at the same time.
◦ They rarely require any surgery unless there is severe bleeding or edema(significant
midline shift)
Epidural heamatoma
◦ Classic hx involves injury with breif loss of conciousness, followed by lucid interval during
which the pat is neurological intact for up to hours. If not treated, this will invariably be
followed by rapid clinical deterioration and death.
◦ It is due to bleeding of middle meningeal artery caousing bleeding btw dura matter
and the bone.
◦ Other symptoms may include headache, focal neurological deficit, and anything
associated with elevated ICP.
◦ CT will reveal lenticular heamtoma usually with midline shift.
◦ All epidural heamatoma will require immediate neursurgical decompression.
Subdural heamatoma
◦ Bleeding btw dura and arachniod mater, usual due to trearing of bridging veins, this
may be due to major truama or due to minor truama in pt with brain atrophy(elderly)
◦ They are caused by severe truama including rapid acceleration/deceleration resulting
in high shear forces.
◦ Acute, chronic and acute on chronic
◦ Symptoms of acute disease are consistence with increasing ICP, lateralizing sign,
forced dilated pupil, chronic disease usually presents as subacute cognitive decline in
an elderly person or an alcoholic due to brain atrophy.
◦ Diagnosed via CT which will reveal a crescenteric hematoma.
◦ Patient should be admitted for observation, drainage is typically performed if there is a
midline shift >5mm or significantly elevated ICP or if chronic.
Subarachnoid hemorrhage
◦ Can either be tuamtic or spontaneous. When they are spontaneous, the most likely
cause is cerebral artery anuerysm.
◦ Classical symptoms: ‘the worst headache of my life’ which occur suddenly and
relentless in pain. Photophobia and meningismus are well.
◦ Diagnosis via CT which will often show bleeding into basilar cisterns(texaco star pattern)
and associated contusion or fracture at the site of injury.
◦ Treatment ICU admission; frequent ICP checks; treatment involve calcium channel
blocker which reduces vasospasm(nimodipine)