HEAD TRAUMA

1
HEAD TRAUMA
By
Dr. Vashdev FCPS , Consultant
Neuro and Spinal Surgeon DEPARTMENT OF
NEUROSURGERY LIAQUAT UNIVERSITY OF MEDICAL AND
HEALTH SCIENCES. JAMSHORO
2
Head Trauma

• Objectives
• To understand the structured approach to the
  patient with head trauma
• To learn how to identify serious and
  life-threatening head injuries

120
3
Head Trauma

• 1/3-1/2 of trauma deaths
• Good outcomes possible without CT scans and
  neurosurgeons
• Aim to avoid secondary brain injury
• Hypoxia and hypotension double mortality
  

121
4
Head TraumaApproach

• Airway
• Breathing
• Circulation

122
5
Head TraumaPhysiology

• CPP MAP - ICP
• CPP cerebral perfusion pressure
• MAP mean arterial pressure
• ICP intracranial pressure

123
6
Cerebral Blood FlowDepends on

• CPP (MAP-ICP)
• PaCO2
• PaO2
• Local metabolites

124
7
Head TraumaPathophysiology

• Primary Injury
• occurs at time of injury
• Secondary Injury
• occurs after injury
• may be preventable

125
8
Head Trauma Primary injury

• Diffuse axonal injury
• Acceleration
• deceleration
• Cerebral contusion
• Penetrating injury

126
9
Head Trauma Secondary injury

• Hypoxia
• Hypoperfusion (? ICP, ? MAP)
• Hypoglycaemia
• Hyperthermia (fever)
• Seizures

127
10
Head TraumaInitial assessment

• Airway ( C-spine)
• Breathing
• Circulation
• Disability ( pupils)
• Exposure

128
11
Head TraumaExamination

• Glasgow Coma Score
• Pupils
• Corneal reflex
• Eye position
• Fundi

129
12
Head TraumaExamination

• Tympanic membrane
• Scalp and skull
• (Raccoon eyes, Battle sign)
• Respiratory Pattern
• Muscle tone
• Posture
• Tendon reflexes

130
13
Head Trauma GCS Eye opening

• Open spontaneously 4
• Open to command 3
• Open to pain 2
• None 1

132
14
Head Trauma GCS Best Verbal Response

• Oriented 5
• Confused 4
• Inappropriate words 3
• Inappropriate sounds 2
• None 1

133
15
Head TraumaGCS Best Motor Response

• Obeys command 6
• Localises to pain 5
• Withdraws to pain 4
• Abnormal flexion 3
• Extensor response 2
• None 1

134
16
Head Trauma Severity of Head Injury

• Severe GCS lt8
• Moderate GCS 9-12
• Mild GCS 13-15

135
17
Head Trauma Pupillary signs

• Size
• Reactivity
• Equality

136
18
Head Trauma Pupillary responses

• Fixed, dilated,
• unresponsive

• Severe hypoxia
• Severe brain Injury
• Hypothermia
• Seizures

137
19
Head Trauma Pupillary responses

• Unilateral, dilated,
• unresponsive

• Expanding lesion on same side
• Tentorial herniation
• Seizures

138
20
Head TraumaAcute extradural or subdural

• Potentially life-threatening
• Immediate recognition essential
• Require burr-hole decompression

139
21

22
Head TraumaAcute extradural

• LOC ? lucid interval ? deterioration
• Middle meningeal artery bleed
• Overlying skull fracture
• Contralateral hemiparesis
• Fixed pupil on side of injury

140
23
Head TraumaAcute subdural

• Tearing of bridging vein between cortex and dura
• Underlying brain injury
• Usually no lucid interval
• Worse prognosis than extradural haematoma

141
24
(No Transcript)
25
Head TraumaOther injuries

• Base-of-skull fractures
• Cerebral concussion
• Depressed skull fracture
• Intracerebral haematoma
• Usually do not require urgent neurosurgery
  consultation

142
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
Head TraumaManagement

• Airway
• Breathing (ventilation)
• Circulation
• Avoid ? ICP
• Aim to prevent secondary injury

143
31
Head TraumaSevere (GCSlt8)

• Intubate
• Normal CO2
• Treat hypotension with fluid
• Sedation /- paralysis

144
32
Head TraumaSevere (GCSlt8)

• Nurse head up 20o
• Prevent hyperthermia
• Complete secondary survey
• Reassess frequently

145
33
FINDINGS WITH LOW RISK OF ICI

• asymptomatic
• headache
• dizzines
• scalp hematoma
• skull x-ray normal
• DISCHARGE on instructions
• change in level of consiousness
• severe headache
• persistent vomiting
• bradycardia

34
FINDINGS WITH MODERATE RISK ICI

• h/o loss of cons.
• progressing headache
• post traumatic seizures
• age lt2 years
• post traumatic amnesia
• vomiting
• signs of BSF
• multiple trauma
• severe facial injuries
• CRITERIA FOR OBSERVATION AT HOME
• normal C.T scan
• GCS - gt14
• reasonable access to hospital

35
FINDING WITH HIGH RISK OF ICI

• Depressed level of Con.
• Focal Neurologic Findings
• Penetrating skull injuries

36
Head TraumaBeware

• Deteriorating conscious state
• Penetrating injury
• Focal neurological signs
• - unequal, dilated pupils
• - seizures
• - posturing

146
37
Head Trauma

• ?

147
38
Head Trauma

• Summary
• ABCs
• Prevent secondary injury
• Isolated head trauma doesnt cause hypotension
• Look for other injuries
• Deterioration ? reassess

148
39
(No Transcript)