1. Head Injury Dr Mohamed EL Hady. Senior Neurosurgeon Specialist K S H

2. Head Injury 44% 5% 21% 11% 6% 12% 1% CARS MOTORBIKES DOMESTIC WORK SPORTS OTHER CAUSES UNKNOWN Causes 3. Head Injury Any trauma to the Scalp Skull Brain Head trauma includes an alteration in consciousness. 4. Common major trauma 4 million people experience head trauma annually Severe head injury is most frequent cause of trauma death At Risk population Males 15-24 males 2x as likely as women Infants Young Children Elderly Head Injuries 5. Head Trauma Usually signifies craniocerebral trauma Includes alteration in consciousness High potential for poor outcome Death at injury Death within 2 hours after injury Death 3 weeks after injury 6. Consciousness State depends on intact cerebral hemispheres Reticular activating system (RAS) in the brain stem midbrain hypothalamus and thalamus Impairment on conscious level occurs due to any lesions in the cerebral hemispheres or in the (RAS) 7. RAS is located in brain stem RAS 8. Unconsciousness An abnormal state in which patient is unaware of self or environment Can be for very short time to long term coma Care is designed to Determine the cause Maintain bodily functions Support vital functions Protect patient from injury 9. Different Types of Injury Head Injury Cranial Injury Brain Injury 10. Head Injuries Scalp wound Highly vascular, bleeds briskly Shock: child may develop Shock: adult another cause Management No unstable fracture: direct pressure, dressings Unstable fracture: dressings, avoid direct pressure 10Head Trauma - 11. Skull fracture Linear nondisplaced Depressed Compound Suspect fracture Large contusion or darkened swelling Management Dressing, avoid excess pressure Before operating Head Injuries 11Head Trauma - 12. Cranial Injury Trauma must be extreme to cause fracture Linear Depressed Open Impaled Object 13. Basal Skull Unprotected Spaces weaken structure Relatively easier to fracture 14. 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 15. Basilar Skull Fracture Battles sign Raccoon eyes 15Head Trauma - 16. Raccoon eyes 17. Cranial Injury Basilar Skull Fracture May tear dura Permit CSF to drain through an external passageway May mediate rise of ICP Evaluate forHalo sign 18. Mechanism of injury Non- missile or closed head injury Acceleration decelaration Coup - counter coup 19. 191919 Acceleration o Direct blow to the head o Skull moves away from force o Brain rapidly accelerates from stationary to in- motion state causing cellular damage Acceleration 19 20. 202020 Deceleration o Head impacts to a stationary object (e.g., car windshield) o Moving skull stops motion almost immediately o However, brain, floating in cerebral spinal fluid (CSF), briefly continues moving in skull towards direction of impact, resulting in significant forces that damage cells Deceleration 20 21. 212121 Coup/Contracoup Injury resulting from rapid, violent movement of brain is called coup and contracoup. This action is also referred to as a cerebral contusion. o Coup: an injury occurring directly beneath the skull at the area of impact o Contracoup: injury occurs on the opposite side of the area that was impacted Coup injury Contracoup injury 21 22. Direct Brain Injury Types Coup Injury at site of impact Contrecoup Injury on opposite side from impact 23. Mechanism of injury Missile or penetrating injuries 24. Crainial Injuries Penetrating trauma 24Head Trauma - Bullet fragments 25. Head Trauma - 26 Forces that cause skull fracture can also cause brain injury. 26. 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. 27. Focal brain injury Brain contusion Bruises on the brain 28. Brain contusion Contusion bruising of brain tissue Has area of necrosis infarction and hemorrhage Often from coup - contrecoup injury Seizures are common after contusion 29. Focal brain injury Blood between skull and duramater Arterial bleed period of lucency relatively uncommon present in 1% of all head-injured patients Epidural hematoma 30. Focal brain injury Epidural hematoma Comes from bleeding between dura and inner surface of the skull Will be unconscious, then awake, and then deteriorate ( lucid interval ) Headache, nausea and vomiting Needs surgical intervention to prevent brain herniation and death 31. Focal brain injury Subdural hematoma > Between the dura mater and the piaarachnoid mater > Occurring in approximately 30% of severe head injuries 32. Subdural Hematoma - - - Usually bleeding is from veins, so bleeding is GENERALLY slower than epidurals CAN be from arteries and these require IMMEDIATE removal Administration of anticoagulants is one of the causes of CHRONIC TYPES esp. in the elderly. 33. Focal brain injury Intracerebral hematoma Can even appear 24 hours following initial insult 34. Traumatic Subarachnoid Hemorrhage Most common CT finding in moderate to severe TBI If isolated head injury, may present with headache, photophobia and meningismus The outcome depends on the Size of bleed Timing of CT Nimodipine reduces death and disability by 55% 35. Traumatic Subarachnoid Hemorrhage 36. 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) 39Head Trauma - 37. Hurgada Red Sea Egypt 38. Cushings Reflex Increased BP Bradycardia Irregular respirations Signs & Symptoms of Brain Injury Vomiting Without nausea Projectile Body temperature changes Changes in pupil reactivity Decorticate posturing 39. Pathophysiology of Changes Frontal Lobe Injury Alterations in personality Occipital Lobe Injury Visual disturbances Cortical Disruption Reduce mental status or Amnesia Retrograde Unable to recall events before injury Antegrade Unable to recall events after trauma Repetitive Questioning Focal Deficits Hemiplegia, Weakness or Seizures Signs & Symptoms of Brain Injury 40. Minor Head Trauma Concussion patient may not lose consciousness Will be a brief change in LOC, patient may not remember the event and will have headache Post-concussion syndrome is 2 weeks to 2 months after injury 41. Post Concussion Syndrome Persistent headache Lethargy Personality changes Short attention span Decreased short-term memory When patient is discharged after concussion nurse should instruct family on what to watch for and when to call Dr. 42. Clinical Manifestations of head injury Change in level of consciousness is the most sensitive and important indicator of neuro status May be pronounced or subtle Early signs may be nonspecific: restlessness, irritability, generalized lethargy 43. Clinical Manifestations Headache From compression on the walls of cranial nerves, arteries and veins Worse in the morning Straining and movement makes worse 44. Clinical Manifestations Vomiting NOT preceded by nausea- unexpected May be projectile 45. Clinical Manifestations Ocular signs Pupil changes are from pressure on third cranial nerve Pupils become sluggish, unequal. This is because of brain shift. May also be pressure on other cranial nerves 46. Clinical Manifestations Decrease in motor function May have hemi paresis or hemiplegia May see posturing either decorticate or decerebrate Decerebrate more serious from damage in midbrain and brainstem Decorticate from interruption of voluntary motor tracts 47. Decerebrated and Decorticted 48. Diagnostic Tests CT MRI Transcranial Doppler studies Looking for vasospasm EEG No lumbar puncture if there is IICP because sudden release of pressure can cause brain to herniate ABGs keep O2 at 100% and PCO2 as related to ICP (25-35) 49. Diagnostic Tests Cervical spine x-ray You must see from 1 7 to see that they have no injury Glasgow Coma Scale (GCS) 50. Glasgow coma scale First described in 1974 by Graham Teasdale and Bryan J. Jennett Lancet 1974, 2:81 51. Glascow Coma Scale Used to document assessment in three areas Eyes opening Verbal response Motor response Normal is 15 and less than 8 indicates coma 52. Glasgow coma scale 53. Minor Head Injury: 13-15 Moderate Head Injury: 9-12 Severe Head Injury (Coma):