HEAD INJURY
(National Brain Centre Hospital & Siaga Hospital)
OVERVIEW
Head injury was first estimated occur in about 1 million years ago Evidenced skull damage on human predecessors now called Australopithecus africanus
Java > 300.000 years ago Peking > 100.000 years ago
Neanderthal > 40.000 years ago
Damage is found that there are two adjacent fracture lines in the posterior region of the skull
QS. Al-Maidah : 27-30 Tells the story of the first murder Adams children (Habil and Qabil) Qabil hit Habil with a rock to the head until Habil killed
BRAIN INJURY
As
defined by the National Head Injury Foundation a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.
HEAD INJURY-EPIDEMIOLOGY
1.5
million Non-fatal TBIs 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBIs 4 billion annually for cost of treatment Peak incidence:
Males age 15-24 years
INTRODUCTION TO HEAD INJURIES
TIME IS CRITICAL Intracranial Hemorrhage Progressing Edema
Increased ICP Cerebral Hypoxia Permanent Damage
Severity is difficult to recognize Subtle signs Improve differential diagnosis
Improves survivability
1ST MANAGEMENT
Primary
survey survey therapy
Secondary Definitive
HEAD TRAUMA
Open
Skull compromised and brain exposed
Closed
Skull not compromised and brain not exposed
Head Trauma - 10
CRANIAL INJURY
Trauma must Linear Depressed Open Impaled Object
be extreme to fracture
DIRECT BRAIN INJURY TYPES
Coup
Injury at site of impact Injury on opposite side from impact
Contrecoup
Pathology of the Brain Injury:
* Not all the brain damage occurs at the time of injury * Basically two main stages of brain damage after injury - PRIMARY DAMAGE - SECONDARY DAMAGE * Last decade : Head CT Scan and MRI played very important role in diagnostic evaluation of head injury patients * Even with improved CT Scan and MRI, the precise type of damage may not be identifiable during life * The principal mechanism are : - CONTACT - ACCELERATION / DECELERATION
PRIMARY DAMAGE
* occurs at the moment of injury
* including : - laceration of the scalp
- fracture of the skull
- contusions and lacerations
- diffuse axonal injury
- intracranial hemorrhage
- other type of brain damage
SECONDARY DAMAGE * results from complicating processes that are
initiated at the moment of injury
* may not present clinically for a period of time afterward * including : - hypoxia / ischemia - swelling - infection - brain damage due to elevated intracranial pressure
BRAIN INJURY
Response to injury
Swelling of brain Vasodilatation with increased blood volume Increased ICP Decreased blood flow to brain Perfusion decreases Cerebral ischemia (hypoxia)
Head Trauma - 16
SIGNS & SYMPTOMS OF BRAIN INJURY
Altered Mental Status Altered orientation Alteration in personality Amnesia Retrograde Antegrade Cushings Reflex Increased BP Bradycardia Erratic respirations
- Vomiting Without nausea Projectile - Body temperature changes - Changes in pupil reactivity - Decorticate posturing
Assessment of Impaired Consciousness
Use practical scale Glasgow Coma Scale Three features are in dependently observed : Points * EYE OPENING Spontaneous 4 To speech 3 To pain 2 None 1 * BEST MOTOR RESPONSE Obeys commands 6 Localized to pain stimuli 5 Withdraws from pain stimuli 4 Decorticate flexion 3 Decerebrate extension 2 None 1 * VERBAL RESPONSE Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
CLINICAL FEATURES Clinical Features Radiological Exam Pathologic name
Mild Head Injury
unconsc < 10 GCS 13 15 no neuro deficit
brain CT normal
Concussion
Moderate Head Injury unconsc 10-<6hrs brain CT abnormal Contusion GCS 9 12 pos neuro deficit Severe Head Injury unconcs > 6 hrs GCS 3 9 pos neuro deficit brain CT abnormal Contusion
SIMPLE HEAD INJURY GCS 15 no neuro deficit no unconsc
DIRECT BRAIN INJURY CATEGORIES
Focal Occur at a specific location in brain Differentials Cerebral Contusion Intracranial Hemorrhage Epidural hematoma Subdural hematoma Intracerebral Hemorrhage Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury
FOCAL BRAIN INJURY
Cerebral Contusion Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma Confusion Neurologic deficit Personality changes Vision changes Speech changes Results from Coup-contrecoup injury
BRAIN INJURIES
Cerebral contusion
Bruising of brain tissue Swelling may be rapid and severe Level of consciousness Prolonged unconsciousness, profound confusion or amnesia Associated symptoms Focal neurological signs May have personality changes
Head Trauma - 22
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Epidural Hematoma Bleeding between dura mater and skull Involves arteries
Middle meningeal artery most common
Rapid bleeding & reduction of oxygen to tissues Herniates brain toward foramen magnum
INTRACRANIAL HEMORRHAGE
Acute epidural hematoma Arterial bleed Temporal fracture common Onset: minutes to hours
Level of consciousness Initial loss of consciousness Lucid interval follows Associated symptoms Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death
Head Trauma - 24
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Subdural Hematoma Bleeding within meninges Beneath dura mater & within subarachnoid space Above pia mater Slow bleeding Superior sagital sinus Signs progress over several days Slow deterioration of mentation
INTRACRANIAL HEMORRHAGE
Acute subdural hematoma Venous bleed Onset: hours to days
Level of consciousness Fluctuations
Associated symptoms Headache Focal neurologic signs High-risk Alcoholics, elderly, taking anticoagulants
Head Trauma - 26
INTRACRANIAL HEMORRHAGE
Intracerebral hemorrhage
Arterial or venous Surgery is often not helpful Level of consciousness Alterations common Associated symptoms Varies with region and degree Pattern similar to stroke Headache and vomiting
Head Trauma - 27
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Intracerebral Hemorrhage Rupture blood vessel within the brain Presentation similar to stroke symptoms Signs and symptoms worsen over time
Basal
Skull
Unprotected Spaces weaken structure Relatively easier to fracture
CRANIAL INJURY
Basal Skull Fracture Signs Battles Signs
Retroauricular Ecchymosis
Associated with fracture of auditory canal and lower areas of skull Raccoon Eyes
Bilateral Periorbital Ecchymosis
Associated with orbital fractures
BASILAR SKULL FRACTURE Battles sign Raccoon eyes
Head Trauma - 31
CRANIAL INJURY
Basilar Skull Fracture
May tear dura Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate for Target or Halo sign
CRAINIAL INJURIES
Penetrating trauma
Bullet fragments
Head Trauma - 33
EDH
SDH
SAH
ICH
THANK YOU
