Zuhair Abu Salma Neurosurgeon R.M.S Head trauma
Mechanism Direct (Blunt vs. Sharp) High vs. low velocity Indirect (acceleration / deceleration
Presentation • Symptoms : headache , nausea , vomitting , seizures , amnesia . • Signs : by examination .
Management in ER • ABC and general examination. • Neurosurgical examination including : 1- Racoon`s eye , Battle`s sign . 2- CSF rhinorhea , otorhea. 3- Epistaxis , otorhagia . 4- GCScale 5- Cranial nerves(pupils size and reaction to light is “SO” important in detecting intracranial haemorrhage) . 6- Motor , sensory and reflexes.
“Glasgow Coma Scale” • Eye opening 4 spontaneous eye opening . 3 to speech 2 to pain 1 no eye opening
Verbal response 5 oriented 4 confused 3 inappropriate 2 non comprehensive 1 no response
Motor response 6 obeying commands 5 localising to pain 4 withdraws limb 3 flexion ( decorticate ) 2 extension ( decerbrate ) 1 no response
Indications for admission to hospital • Any moderate or severe head injuries • LOC >15 min. PTA > 1 hr. • Skull fractures • Base skull fractures • Neurological deficit • Fits • Special cases (observation, alcohol consumption, anticoagulation)
Mild head injury GCS 14-15 • Moderate head injury GCS 9-13 • Severe head injury GCS 5-8 • Critical GCS 3-4 • Usually “intubation” is needed if GCS =< 8 • 60 % of pts with GCS =< 8 have other organ lesions , and 25 % have surgical lesions , and 5 % have cervical fractures.
Investigations • CBC , KFT • Radiological investigations Skull X-ray ,”non-contrasted Brain CT-scan” .
Brain concussion • AKA mild traumatic brain injury. • Def. :alteration of conciousness (confusion , amnesia , or LOC ) without structural damage as a result of nonpenetrating traumatic brain injury. • Rx : supportive .
Diffuse Axonal Injury (D.A.I) • A primary brain lesion causing Coma without space occupying brain lesions . • Due to acceleration or deceleration injuries ( shearing injury ). • Rx : supportive .
Skull fractures • Linear skull fractures : usually conservative Rx . • Depressed skull fractures : may need surgical elevation . • Base of skull fractures : risk of CSF leak and meningitis .
Supportive Rx for mild H.I • V/S observation . • GCS assessment . • Neurological assessment . • Head elevation 30 degrees . • Analgesia without sedation .
Non surgical Rx in I.C.U • Antiepileptics are used to control early post traumatic fits ( < 1 week ) in SDH , penetrating skull injuries , EDH , cerebral contusions … etc. • Intracranial pressure monitoring (ICP-monitoring) • Mannitol , diuretics in Rx of cerebral edema . • “Hyperventilation” to decrease ICP. • These are usually used for subarachnoid haemorrhage (SAH) , cerebral swelling and cerebral contusions .
Surgical Rx • Surgical evacuation of Extraduralhaematoma (E.D.H) , Subdural haematoma (S.D.H) , large Intracerebralhaematoma (I.C.H) , while Subarachnoid haemorrhage needs thorough follow up . • Surgical elevation of depressed skull fractures . • External Ventricular Drain (E.V.D) for intraventricularhaemorrhage . • V-P shunt for Hydrocephalus .
Gunshot wounds to the head • Most lethal type of head injuries. • WORST prognosis when : 1- the bullet traverses the midline of the brain . 2- the bullet pass through ventricles . 3- the bullet pass through more than one brain lobe . 4- resulting in intracranial hematomas . 5- Suicidal injuries .