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Evaluation & management of head injured patient. Classification of Head Injuries. blunt and penetrating injury closed and open head injury Or neurologically speaking closed or blunt inj. can be classified Concussion Contusion Laceration Diffuse axonal injury. MECHANISMS OF INJURY.
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Classification of Head Injuries • blunt and penetrating injury • closed and open head injury Or neurologically speaking closed or blunt inj. can be classified • Concussion • Contusion • Laceration • Diffuse axonal injury
MECHANISMS OF INJURY • inertial or contact mechanisms • Inertial injuries are commonly called "acceleration" or "deceleration" injuries • Contact injuries are commonly called coup & contercoup injuries.
MECHANISMS OF INJURY • The brain is damaged by one or both of two mechanisms: (1) through strains produced within the brain tissue itself and (2) through differential movements between the brain and the skull. • Contact injuries occur both at the site and remote from the point of impact on the head and result in skull fractures and contusions.
Penetrating Injuries • Gunshot wounds to the head are a major cause of morbidity and mortality in large urban areas • bullets can cause damage to brain parenchyma through three mechanisms: • (1) laceration and crushing; • (2) cavitation; and • (3) shock waves.
Secondary Brain Damage SYSTEMIC INSULTS 5 Hs • Hypoxia • Hypotension • Hypercapnia • Hyperthermia • Hyperglycemia and hypoglycemia
Traumatic Unconsciousness • "Coma" is applied to more profound impairment of consciousness, defined many years ago by the Head Injury Committee of the World Federation of Neurosurgical Societies as "an unrousable, unresponsive state, regardless of duration; eyes continuously closed. • There is now no merit in continuing to use terms to qualify the depth of coma (e.g., "light," "semi coma") or terms such as "drowsy" or "stupor,"
How to evaluate the patient • The evaluation depend mainly on 2 things The Glasgow coma scale The examination of pupil
a severe head injury = A Glasgow Coma Scale score of 8 or less at the time of admission • A moderate head injury = A Glasgow Coma Scale score of 9-12 • A minor head injury = A Glasgow Coma Scale score of 13-14
Pupil examination • E.R.T.L. • IN Equality ☼☼The triad of a deteriorating level of consciousness, pupillary dilatation, and an associated hemiparesis = highly suggestive of a hemispheric mass lesion causing transtentorial herniation
Pathology and Pathophysiology of Head Injury • DAMAGE TO THE SCALP • SKULL FRACTURES • Basilar Skull Fractures • Vault skull fractures • Linear • Sutures diastasis • Depressed Fracture • Traumatic Hematomas • Brain Stem Trauma • Cranial Nerve Injuries
BRAIN SWELLING Intracellular (cytotoxic) Extracellular (vasogenic)
Diagnosis and Treatment of Moderate and Severe Head Injuries PREHOSPITAL CARE ABCs S = Sugar • securing the patient's airway, A • ensuring adequate oxygenation, B • initiating fluid resuscitation, C • stabilizing the cervical and thoracolumbar spine, • identifying and stabilizing extracranial injuries, • and assessing the patient's level of consciousness. • Obtaining information on the mechanism of injury and
IN-HOSPITAL RESUSCITATION AND EVALUATION Hypoxia and Airway Management(Specific indications for intubation) Hypotension and Fluid Resuscitation (systolic blood pressure of less than 90 mm Hg was associated with an increase in mortality of 85 per cent.) ►►irreversible brain stem failure
Fluid Resuscitation • Ringer's lactate solution normal saline 273 mOsm per kg 308 mOsm per kg • Recently, hypertonic saline 7.5% + Dextran • 3 per cent saline was associated with normal intracranial pressure • ☺☻no significant difference in outcome has been seen when comparing clinical series of colloid versus isotonic crystalloid fluid resuscitation.
Up to date ►► Rapid infusion of 1 to 2 L of 0.9 per cent isotonic saline is generally effective in hemodynamically stabilizing most trauma victims. ►► combination of normal saline and colloid (5 per cent albumin) in a three-to-one or four-to-one ratio when rapid, high-volume resuscitation is required.
History & examination • In the moderate or severely injured patient (Glasgow Coma Scale of 13 or less), • History • examination • level of consciousness, • the pupillary light reflexes, • extraocular eye movements, • lower brain stem reflexes for patients in deep coma, and • the motor examination.
