HEAD INJURY

AND TRUMATIC

BRAIN INJURY

Dr.Mansoor KhanMBBS, FCPS-I,Resident SCW, KTH, Peshawar

Mar14th, 2009

“Traumatic Brain Injury is an insult to the brain caused by an

external physical force”

TBI

CLOSED HEADINJURY

OPEN HEADINJURY

No obvious external signs, resulting from –motor vehicle crashes, falls, child abuse, or domestic violence, child violence..

Obvious external woundFor example a gunshot wound or object penetrating the skull.

Highest among adolescents, young adults, and those older than 75

Vehicle crashes are the leading cause of brain injury. Falls are the

second leading cause

50% of major trauma deaths are due to TBI

Motor Vehicle Crashes Crashes- 44%Falls - 26%

Other/Unknown - 13%Non-Firearm Assaults Assaults- 9%

Firearms Firearms- 8%

These days there is a new category of Head injury ––

BLAST INJURY!

How grave are the conditions!!!!!!!!

The Annual cost of TBI to the U.S.is equal to one of these

$60.0 Billion!!

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TYPES OF HEAD INJURY

CONTUSIONS

EXTR-DURALHEMATOMA

SUB-DURALHEMATOMA

DIFFUSE AXONAL INJURY

INTRA-CEREBRALHEMORRHAGE

SUB-ARACHNOIDHEMORRHAGE

BLEEDING

LACERATIONSSecure ABC

Expose, clean, apply pressure dressing if bleeding

When the brain suddenly shifts When the brain suddenly shifts inside the skull and knocks against inside the skull and knocks against

the skulls bony surface. the skulls bony surface. Concussions can last from a few Concussions can last from a few

moments, to an unconscious state moments, to an unconscious state for over 3 minutes.for over 3 minutes.

CONCUSSION

Grade 1 Grade 2 Grade 3Allow casualty to rest, however continually monitor in case their condition changes. Lay casualty down with their head and shoulders slightly raised

Seek professional medical assistance, lay the casualty down with the head and shoulders slightly raised. Try to keep casualty awake and talking

Call an ambulance immediately, lay casualty down with head and shoulders slightly raised, try to keep them awake and talking. If casualty falls unconscious and is not breathing, commence CPR and monitor vital signs

Grade 1 – conscious, symptoms last under 15 minutesGrade 1 – conscious, symptoms last under 15 minutesGrade 2 – conscious, symptoms last over 15 minutes Grade 2 – conscious, symptoms last over 15 minutes Grade 3 - unconsciousGrade 3 - unconscious

CONCUSSION

Skull

Contusion, or bruising of the brain

may occur at the site

of the blow.

Brain

Area of bruising

Site of impact

POSSIBLE SITE OF BRAIN INJURY FOLLOWING A BLOW TO BACK OF HEAD

BRAIN CONTUSIONS

Conduct Primary SurveyConduct Primary Survey

If symptoms indicate severe If symptoms indicate severe head trauma, call ambulancehead trauma, call ambulance

Monitor casualty’s level Monitor casualty’s level of consciousnessof consciousnessIf casualty falls unconsciousIf casualty falls unconsciousand breathing ceases, commence and breathing ceases, commence CPR until further help arrivesCPR until further help arrives

BRAIN CONTUSION

EXTR-DURAL HEMATOMA

Blow to the temporal, parietal boneRupture of the middle meningial artey

Initial concussion followed by lucid interval

Respects the suture lines.Seen on CT Brain as lens-shaped blood collectionwith a convex medialborder .

Carries a 5% to 20% mortality rate

Severe head injury-Sudden deceleration injuries

Rupture of a bridging vein

Thin layer of blood in the subdural space

Crescent-shaped blood collectionswith a concave medial border. This does not resect the suture lines. Note also midline shift.

SUB-DURAL HEMATOMA

SUB-ARACHNOID HEMORRHAGE

Bleeding occurs between the arachnoid and pia mater

Increased attenuationis seen in the CSF spacesover the cerebralhemispheres

INTRA-CEREBRAL HEMORRHAGE

Injury of the brain substance itselfAssociated with cerebral laceration,

contusion, oedema and necrosisEvacuation of the clots can have poor

resultsNot as easy to remedy.

DIFFUSE AXONAL INJURY

Occurs due to shearing forces between grey and white matter.

Generalized cerebral oedema results due to parenchymal disruption leadsing

to an increase in ICPRanges from mild form-concussion

severe form- persistent vegetative state

Glasgow coma scale

Fully conscious (GCS 15)

Confused (GCS 9-14)

Comatose (GCS 3-8)

Mild Head injury. GCS 13 – 15 80%

Moderate Head injury GCS 9 – 12 10%

Severe Head injury GCS < 9 10%

GCS<13 at any point

GCS 13-14 at 20

Focal deficit

? Open/depressed/Basal #

Post-traumatic seizure

> 1 vomiting episode

LoC or ante grade amnesia

No imaging now

CT within 1hr

+ Get help!

-When to do CT- Scan

Age 65

Coagulopathy/warfarin

+

+

Dangerous Mex: pedestrian rta, ejection, fall > 1m / 5stairs.

Retrograde amnesia>30mins

-

--

CT within 8hrs

+

Deep cuts or tears to the scalpNauseaVomiting

Severe headacheVisual disturbance

Drowsiness or difficulty being arousedUnequal sized pupils, or pupils that do not

respond to lightParalysis, numbness or loss of function over

one half of the bodyProblems with balance

Fluid flowing from eyes and/or mouthDrunken behaviour

Fits, confusion or unconsciousness

PRESENTATION

Intense headache, worse when lying flat and/or with physical exertion

Unequal or dilated pupilsVomiting

Weakness on one side of the bodyNoisy, irregular breathing

Irritable or aggressive behaviour

INCREASED

ICP

Sedate and intubateNurse patient at 30 degree angle-aids

venous drainageMild hyperventilation- keep pCO2

approx 4.5kPa- if allowed to fall lower this leads to vasoconstriction and

subsequent ischaemiaMild hypothermia

INCREASED

ICP

INCREASED

ICP

Surgical management

Burr holesEvacuation of mass lesion +/-

craniectomyDecompressive craniectomy

THANKS