HEAD INJURY
Getrude Kashinge 4th Year
David Kazeze 6th Year
contents
• INTRODUCTION
• BRIEF ANATOMY
• CLASSIFICATION
• CLINICAL ASSESSMENT
• MANAGEMENT
• REFERENCES
Introduction
• Head injury is defined as traumatic damage that affects any of the
structures of the head ( face, scalp,skull, brain, blood vessels and
meninges).
• Head injuries account for 1 % of all deaths and 25% of all trauma
deaths
• They are responsible for 50% of all deaths from road traffic accidents
Basic Anatomy
• Scalp
• Skull
• Meninges
• Dura Mater
• Arachnoid
• Pia Mater
• Brain Tissue
• CSF and Blood
ANATOMY OF THE HEAD ( LAYERS OF THE
SCALP)
BLOOD SUPPLY TO THE BRAIN
( CIRCLE OF WILLIS)
• ACA; Supply the middle portion of the frontal lobe and the superior
medial parietal lobe
• MCA; supply the lateral surface of the hemisphere excepts the parietal
lobe[ via ACA ] and the inferior portion of the temporal and occipital
lobe
• The ACA, ACOM and MCA forms the anterior half, known as the cerebral
circulation
• Posteriorly, the basilar artery BA, formed from the left and right
vertebral arteries, branches into a left and right posterior cerebral artery
PCA therefore forming the Posterior Circulation.
• The PCAs mostly supply blood to the temporal lobe
Classification of Head Injury
• General classification
• Etiological classification
• Clinical classification
• Pathological classification
• Morphological classification
GENERAL CLASSIFICATION
• Open injuries: any injuries with communicating wounds and CSF
leakage.
• Closed injuries: injuries without communicating wounds or CSF
leakage
ETIOLOGICAL CLASSIFICATIONS
• MISSILE INJURIES :
• High velocity : Produce focal and diffuse widespread distraction. e g Gunshot.
• Low velocity: Catapult, golf ball, skull fractures and epidural hematoma (injury
to middle meningeal artery) - May cause focal injury
• NON MISSILE INJURIES
• High velocity:
• Typically motor accidents
• Acceleralation / deceleration, rotational and direct impact injuries, associated
with diffuse neuronal and axonal injuries
Cont’d
• Low velocity
• During a fall or in assault.
• striking the head against an object
• Injury localized at the site of impact
(coup).
• Injury at opposite site of impact
(contracoup).
CLINICAL CLASSIFICATION
Pathological classification
PRIMARY INJURY : Arise from the initial injury at the time of impact.
Results of mechanical forces producing tissue deformation.
• This includes:
• Scalp laceration
• Skull fractures
• Vascular- epidural, subdural, intracerebral/intraventricular and
subarachnoid hemorrhage)
• Meninges
• Cerebral lacerations
• Neuronal + axonal injury (without sign on head or face)
SECONDARY INJURY:
• includes any insults that occur after primary injury
• Secondary manifestation of the craniocerebral trauma that is delayed in
onset.
• Often due to secondary insults that include:
• Poor oxygenation (hypo-ventilation)
• Poor perfusion (hypo-perfusion)
• Ischemic hypoxia and infarction
• Hypoglycemic hypoxia
• Cerebral edema
• Cerebral herniation
Morphological classification
• Classified according to the type of injury that has occurred
• They can either be diffuse intracranial lesions or focal intracranial lesions
• Focal intracranial lesions
• Contusion: results from focal trauma parenchyma blood vessels leading to
petechial hemorrhages and edema
• Intracerebral hemorrhage: caused by tearing of intracranial blood vessels. It
includes epidural and subdural hematoma
• diffuse intracranial lesions
• Concussion: Altered mental state that may or may not include loss of
consciousness
• Diffuse axonal injury: Caused by microscopic shearing of nerve fibres with
patents being often comatose for prolonged periods of time
The Monro-Kellie Doctrine
• The Monro-Kellie Doctrine states that the total volume within the skull is fixed
and made up of brain tissue, blood, and cerebrospinal fluid (CSF).An increase in
one component must be balanced by a decrease in one or both of the others to
maintain normal intracranial pressure (ICP).
• If this balance is disrupted, ICP rises, which can affect brain function and blood
[Link] perfusion pressure (CPP) = Mean arterial pressure (MAP) – ICP.
• CPP is the pressure that drives blood flow to the brain, supplying it with oxygen
and nutrients.
• As ICP increases (due to swelling, bleeding, or a mass), CPP decreases.
• Reduced CPP leads to decreased brain perfusion.
• Autoregulation allows the brain to maintain constant blood flow by adjusting
blood vessel [Link] mechanism works best when CPP is within the
normal range of 60 to 150 mmHg.
Cont’d
• When ICP starts to rise, the body attempts to maintain cerebral
perfusion pressure (CPP) by increasing MAP. This is called cushing
reflex or triad(systolic hypertension,bradycardia and irregular
respirations
• Cushings reflex may be seen in the terminal stages of head injury and
may indicate impending brain herniation.
• Other symptoms/signs of raised ICP include Diminishing level of
consciousness,Headache, vomiting, seizures, unequal Pupillary
changes and Papilloedema
CLINICAL ASSESSMENT
• PRIMARY SURVEY : ABC(with cervical collar until fracture is ruled out
by imaging)
• SECONDARY SURVEY :
• History And Full Examination
• investigations
HISTORY
• Mechanism of injury: direct trauma to the head or deceleration
• Time of injury
• History of : loss of consciousness (LOC) & did the patient regain it
(Lucid interval), Convulsions, bleeding from ears/nose or any
discharge
• History of alcohol intake
• Headache, nausea, vomiting
• Last meal
• Medication and co- morbidities
EXAMINATION
• Full neurological examination including:
• GCS
• Pupil light responses and reflexes: pupillary inequalities(anisocoria) or
abnormal light reflex indicate intracranial hemorrhage
• External evidence of head injury such as
• CSF rhinorrhoea or otorrhoea (Test: halo sign)
• Battle sign: bruised mastoid
• Raccoon sign: bilateral orbital bruising
• Haemotypmanum
• Lacerations
• Open wounds
MANAGEMENT
• INVESTIGATION
• Diagnostic investigations
• Supportive investigations
• TREATMENT
• General/initial treatment
Investigations
• Diagnostic investigations
• CT scan.
• X-rays: Skull x-ray (AP and Lateral.
• MRI.
• Carotid arteriography.
• Supportive investigations
• FBC, Cross match/ group and save
• Creatinine, LFTs, RBS, ABG (Arterial blood gases)
• Urea and Electrolytes
General/initial management
Primary survey
Airway and breathing with stabilization of C spine
• Head must be positioned at 30 degrees
• Airway protection with oral airway, endotracheal intubation when
indicated
• Maintain oxygen saturation at >90%
Circulation
• Fluids
• Keep systolic BP at >90mmHg
• Maintain mean arterial pressure at 80
Cont’d
• Analgesia for pain
• Keep patient warm
• Manage scalp wounds accordingly(cleaning & debridement)
• Antibiotics e.g Penicillins, Ampicillins
• Prophylactic seizure medication(carbamazepine,phenobarbital)
• Assess if they can swallow(if NG tube is required)
Indications for surgery(craniotomy):
• Epidural hematoma
• Acute subdural hematoma
Management of Raised intracranial pressure
• ABCDE assessment and stabilization: : -
• If head/neck injury is suspected, protect and stabilize the C-spine as a priority
• If the airway is at risk if GCS <8. Use airway control with airway manoeuvres,
adjuncts as appropriate
• Breathing –ventilate as required, give oxygen
• Circulation –maintain mean arterial pressure with vasopressors if required
• Elevate head of bed by15 –30 degrees.
• Consider hyperventilation if available, with close monitoring (note –effects
only last for minutes).
• Give 20% mannitol if available, with close monitoring.
• Give 3% saline if available, with close monitoring.
COMPLICATIONS OF HEAD
INJURIES
• EARLY COMPLICATIONS :
• Brainstem injuries
• CSF rhinorrhea
• Meningitis
• Pituitary damage and endocrine failure
• CSF otorrhea
• LATE COMPLICATIONS :
• Chronic subdural hematoma
• Early posttraumatic epilepsy
• Posttraumatic amnesia
• Posttraumatic hydrocephalus
• Posttraumatic headache.
References
• Medscape article ‘Head Injury’
[Link]
• Mannipal Manual of Surgery 4th Edition
• SRB’s Manual of Surgery 3rd Edition
