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Head Injury

Head Injury

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Head Injury

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  1. Head Injury Saurabh Sinha Department of Clinical Neurosciences Western General Hospital

  2. Age Groups

  3. Mechanisms of Injury

  4. What now?

  5. Resuscitation • A airway with cervical spine control • B breathing • C circulation

  6. Traumatic Brain Injury Immediate impact injury • Contusions and lacerations • Diffuse damage to white matter • Other types of diffuse brain injury Primary complications • Intracranial haemorrhage • Brain swelling Secondary complications • Brain damage secondary to raised ICP • Hypoxic brain damage • Infection

  7. Aims • Prevent secondary brain injury • Rapid transfer to hospital

  8. Brain Herniation

  9. Uncal Herniation

  10. Midbrain Infraction

  11. Cerebral Physiology • Intracranial pressure (ICP) 0-10 mmHg • Cerebral perfusion pressure (CPP) >60 mmHg • Obligative aerobic glycolysis • Cerebral blood flow (CBF) maitained by autoregulation

  12. Severe Head Injury • Raised ICP • Reduced CPP • Loss of autoregulation • Neuroexcitotoxicity

  13. Raised ICP • Seizures • Brain swelling • Vasogenic oedema • Intracranial haematoma • Hypercarbia • Hypoxia

  14. Neurological Assessment • Level of consciousness (GCS) • Pupillary reaction to light • Limb movements • History

  15. Complicating Factors • Alcohol • Drugs • Epilepsy • Stroke • Cervical spine injury

  16. Eye (1-4) open spontaneously open to speech open to pain no opening Motor (1-6) obeys commands localises to pain normal flexion abnormal flexion extension no movement Verbal (1-5) orientated confused inappropriate words incomprehensible sounds none GCS 3-15 Best score using upper limbs Special cases dysphasia periorbital oedema endotracheal tube/tracheostomy The Glasgow Coma Scale and Score

  17. Definition of Coma • GCS 8 or less • No eye opening • Does not speak • Does not obey commands

  18. Dilated Pupil

  19. Signs • Penetrating Injury • Scalp laceration or haematoma • Periorbital haematoma • Blood or CSF from nose • Blood or CSF from ear • Battle’s sign • Cranial Nerve (eye movements, facial weakness)

  20. Subconjunctival Haemorrhage

  21. Panda Eyes

  22. Battle’s Sign

  23. Indications for skull X-ray • Orientated Patients • History of LOC/amnesia • Suspected penetrating injury (?CT) • CSF/Blood from ear/nose • Scalp laceration (to bone or >5cm), bruise or swelling • Persistent headache or vomiting • Children • Fall from significant height • Onto hard surface • Tense fontanelle • Suspected NAI • Patients with impaired consciousness or neurological signs • All patients unless CT or neurosurgical transfer arranged

  24. Skull Fracture

  25. Depressed Skull Fracture

  26. Aerocoele

  27. Penetrating Injury

  28. Risk of operable intracranial haematoma in head injured patients • GCS 15 (1:3615) 1 in 31300 • With PTA 1 in 6700 • Skull fracture 1 in 81 • Skull fracture & PTA 1 in 29 • GCS 9-14 (1:51) 1 in 180 • Skull fracture 1 in 5 • GCS 3-8 (1:7) 1 in 27 • Skull fracture 1 in 4

  29. Indication for urgent CT/NS referral • Coma persisting after resuscitation • Deteriorating conscious level or progressive neurological signs • Skull fracture & confusion/seizure/neuro symptoms or signs • Open injury: compound depressed #, gunshot or penetrating injury

  30. Haematoma

  31. Contusion

  32. Multiple Contusions

  33. Extradural Haematoma

  34. Subdural Haematoma

  35. Chronic Subdural Haematoma

  36. Diffuse Axonal Injury

  37. Extradural Haematoma

  38. Skin Preparation

  39. Craniotomy Mark

  40. Opening

  41. Dura

  42. Subdural Haematoma

  43. Subdural Collection

  44. Haemostasis

  45. Monitoring

  46. ICP Monitoring

  47. GCS Chart