HEAD INJURIES

Presented By :

• Ghalib Hussain Khan• Bs. Physiotherapy • Institute Of Physiotherapy

LUMHS Jamshoro Sindh

• Email: dr.khan127@gmail.com

• Facebook: www.facebook.com/ghalib.khan09

OUTLINES:

• Introduction• Epidemiology• Etiology• Symptoms• Types

• Scalp• Skull• Brain Basic Anatomy

• Primary• Secondary• Brain Injuries

• Complication• Management• Rehabilitation

Introduction

• Injury to the head may damage the scalp, skull or brain.

• The most important consequence of head trauma is traumatic brain injury.

• Number One Killer in Trauma • 25% of all trauma deaths• 50% of all deaths from MVC• 200,000 people in the world live with the

disability caused by these injuries

Epidemiology

• 1.5 million Non-fatal TBI’s• 370,000 Hospitalizations• 80,000 cases of neurological sequela• 52,000 Die from TBI’s• 4 billion annually for cost of treatment• Peak incidence:

• Males age 15-24 years• Causes of TBI

• Young: GSW• Old: Falls

Etiology• Motor vehicle accidents• Firearm-related injuries• Falls• Sports-related injuries• Recreational accidents

• Missile wounds• Stab wounds(most common knife injury)• Occupational accidents (nails, rewdrivers). • Nails,• Metal poles • Ice picks• Keys, pencils• Power drills.

Symptoms

unconsciousness, either very briefly (concussion) or for a longer period of time

• difficulty staying awake or still being sleepy several hours after the injury 

• having a seizure or fit (when your body suddenly moves uncontrollably)

• difficulty speaking, such as slurred speech

• vision problems or double vision • difficulty understanding what people say • reading or writing problems • balance problems or difficulty walking. • loss of power in part of the body, such as

weakness in an arm or leg • amnesia (memory loss), such as not being

able to remember what happened before or after the injury

• clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)

• a black eye (with no other damage around the eye) • bleeding from one or both ears • new deafness (loss of hearing) in one or both ears • bruising behind one or both ears • a lasting headache since the injury • vomiting since the injury • irritability or unusual behaviour • visible trauma (damage) to the head, such as an open,

bleeding wound

Signs and Symptoms Glasgow Coma Scale

Types of Head InjuriesTypes of Head Injuries

• Scalp lacerations

• The most minor type of head trauma• Scalp is highly vascular profuse bleeding• Major complication is infection

• Scalp lacerations

• The most minor type of head trauma• Scalp is highly vascular profuse bleeding• Major complication is infection

TypesTypes

• Skull fractures

• Linear or depressed• Simple, comminuted, or compound• Closed or open• Direct & Indirect• Coup & Contrecoup

• Skull fractures

• Linear or depressed• Simple, comminuted, or compound• Closed or open• Direct & Indirect• Coup & Contrecoup

Types of Head InjuriesTypes of Head Injuries

• Skull fractures

• Location of fracture alters the presentation of the manifestations

• Facial paralysis• Conjugate deviation of gaze• Battle’s sign

• Skull fractures

• Location of fracture alters the presentation of the manifestations

• Facial paralysis• Conjugate deviation of gaze• Battle’s sign

Brain Injuries

Basic Anatomy

• Scalp

• Skull

• Meninges• Dura Mater• Arachnoid• Pia Mater

• Brain Tissue

• CSF and Blood

Skull

Dura- mater

Venous sinuses

Arachnoid mater

Pia- mater

CSF

Grey matter

White matter

Ventricles

Brain Injuries

• Primary (Direct) Brain Injuries

• Secondary (Indirect) Injuries

Primary Brain Injuries

• It occur at the time of impact

• Direct damage done to brain parenchyma and associated with vascular injuries

• Mechanical irreversible damage - brain lacerations, hemorrhages, contusions, and tissue avulsions,

Secondary Brain Injury

• Damage that occurs after the initial insult (ongoing injury processes)

• Expanding mass lesions, swelling or bleeding quickly overwhelm buffers

• End result is increased intracranial pressure (ICP) and/or herniation

Secondary Injury Mechanisms

• Elevated ICP and mechanical shifting leading to herniation

• Hypoxia • Hypotension and inadequate

Cerebral Blood Flow • Cellular mechanisms

Intracranial Causes

• Herniation: displaced brain parenchyma• Damage to brain from trauma against the dura itself

as well as producing ischemia as well• Cerebral Edema: intracellular fluid collection within

neurons and interstitial spaces. • Intracerebral Hematomas

Brain Injuries – Brain Concussion

• Usually caused by blunt injuries. • Injuries patient shows transient alteration

in neurologic function • Mild injury usually with no detectable brain

damage. • May have brief loss of consciousness. • Headache grogginess and short memory

loss are common.

Brain Injuries – Brain Contusion

• A bruised brain or contusion can occur with closed head injuries.

• Usually caused by blow that causes the brain to hit inside the skull

• Unconsciousness or decreased level of consciousness can occur

Brain Injuries – A hematoma

• Is a collection of blood within tissue. • Hematoma inside the cranium is named

according to its location:• Subdural hematoma: blood collection

between brain and dura • Epidural hematoma: blood collection

between dura and the skull• Subarachnoid Hemorrhage: • Intracerebral hematoma: blood

collection within the brain

Epidural Hematomas

• Blood between inner table of the skull and the dura

• Lens shaped hematomas that do not cross suture lines on CT

Subdural Hematomas

• Blood beneath the dura, overlying the brain and arachnoid, resulting from tears to bridging vessels

• Crescent shaped density that may run length of skull

• Very common in the elderly

Subarachnoid Hemorrhage • Bleeding beneath the

arachnoid membrane on the surface of the brain.

Intracranial Hematoma• Focal areas of

hemorrhage within the parenchyma

Care of Skull Fractures and Brain Injuries

• Take appropriate body substance isolation precautions.

• Assume spine injury • Monitor conscious patient for

changes in breathing• Apply rigid collar, immobilize the

neck and spine • Administer high concentration

oxygen • Control bleeding

• Keep patient at rest • Talk to conscious patient

(emotional support) • Dress and bandage open

wounds • Mange the patient for shock • Be prepared for vomiting • Transport patient promptly • Monitor vital signs every five

minutes

Complications-Long Term Sequela

• Seizure Disorder• 2% Early post-traumatic incidence

• Increased to 30% in children, alcoholics and with intracranial hematoma

• Prophylactic antiepileptics reduce early occurrence

Complications-Long Term Sequela

• Concussion

- Brief LOC - Vertigo - Nausea

- Dizziness - Headache- Vomiting

- Photophobia (An abnormal or irrational fear of light)

- Cognitive/Memory dysfunction• Up to 80% may have symptoms at 3

months• 15% may have symptoms at 1 year• 85-90% recover after 1 year

Complications-Long Term Sequela

• Infection• Skull fracture• CSF leak• Intubation

• History of Fracture• Fever• Signs of meningitis

• 3rd generation cephalosporin• Vancomycin

• ICU

• Treatment• Prophylactic antibiotics

Management

• Airway• Suctioning• Patient positioning• OPA and NPA use• Endotracheal intubation

• Orotracheal• Nasotracheal

• Cricothyrotomy

• Breathing• Oxygen

• 15 LPM/NRB

• Ventilations• 12–20/min• Hyperoxygenate• ETCO2 maintained at 35–40

mmHg• Continuous waveform

capnogrpahy• Circulation

• Hemorrhage Control• Blood pressure maintenance

• Fluid resuscitation to SBP of 90 mmHg

Medications

• Diuretics.

• Anti-seizure drugs.

• Coma-inducing drugs.

Surgery

Removing clotted blood (hematomas).

• Repairing skull fractures.

• Opening a window in the skull.

Rehabilitation:

• Physiatrist, a doctor trained in physical medicine and rehabilitation, who oversees the entire rehabilitation process

• Occupational therapist: helps the person learn, relearn or improve skills to perform everyday activities

• Physical therapist: helps with mobility and relearning movement patterns, balance and walking

• Speech and language pathologist, who helps the person improve communication skills and use assistive communication devices if necessary

• Rehabilitation nurse

• Traumatic brain injury nurse specialist, who helps coordinate care and educates the family about the injury and recovery process

• Recreational therapist, who assists with leisure activities

• Vocational counselor, who assesses the ability to return to work and appropriate vocational opportunities, and provides resources for addressing common challenges in the workplace