Head injury

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Head InjuryKyaw San Lin (RN – 21)Kaung Thet Han (RN – 12)Kyaw Khan Zaw (RN – 17)Final year - Part 2 M.B.B.S.

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Contents Physiology & Pathophysiology Epidemiology Initial evaluation and management History Examination Classification Management Outcomes

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Physiologycerebral perfusion pressure (CPP) = MAP − ICP (75–105 mmHg) = (90–110 mmHg) - (5–15 mmHg)

Normal cerebral blood flow (CBF) = 55 mL/minute for every 100 g of brain tissue<20 mL/min ischaemia

Cerebral perfusion is kept constant across a range of perfusion pressures by the process of autoregulation.Autoregulation is compromised in the injured brain.

N. S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.

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PathophysiologyCerebral hypoxia

ATP depletion

failure of Na+/K+ pump

intracellular accumulation of Na+ and Ca+2

acidosis, decreased NT uptake

M. G. H. Gephart. Tarascon Neurosurgery Pocketbook. Jones & Bartlett Learning, 2014.

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Pathophysiologyglycolysis inhibition, increased extracellular glutamate

activation of NMDA channel

increased intracellular Ca+2

protease/phospholipase activation

free fatty acid (free radical accumulation)


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PathophysiologyImpairment of autoregulation of cerebral blood flow

decoupling of cerebral metabolism and cerebral blood flow


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Monro-Kellie doctrine


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Head Injury: Epidemiology 12th leading cause of mortality in Myanmar – 2.7%

Health in Myanmar 2014, Ministry of Health, The Republic of the Union of Myanmar, 2014.

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Initial evaluation and management

Resuscitation performed according to ATLS guidelinesA, Airway with cervical spine protectionB, Breathing and ventilationC, Circulation with haemorrhage controlD, Disability: neurological statusE, Exposure: completely undress the patient and assess for other injuries


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History•Bystanders and paramedics may give vital information on the:pre-injury state (fits, alcohol, chest pain)energy involved in the injury (speed of vehicles, height fallen)conscious state and haemodynamic stability of the patient after the accidentlength of time taken for extrication

•the length of retro- and antegrade amnesia useful for grading severity

•medication history, especially anticoagulants


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The Standard Observation Chart

A. H. Kaye. Essential Neurosurgery, 3rd Edition. Blackwell, 2005.

Examination: Primary survey•Ensure adequate oxygenation and circulation

•Check pupil size and response and GCS as soon as possible

•Check for focal neurological deficits before intubation if possible

•Check blood sugar for hypoglycaemia

19N. S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.

Examination: secondary survey

•A full secondary survey will be required.

•Particular attention must be paid to the head, neck and spine.

20Harold Ellis et al. Lecture Notes: General Surgery, 12th Edition. Wiley-Blackwell, 2011.

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Head•Look and feel over the whole skull and face for cuts, bruises and fractures.

•Check for fractured base of skull by looking for blood in the ears, nose or mouth and Battle’s sign.


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Battle’s signA skull base fracture may be associated with bruising over the mastoid process.


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Racoon Eyes or Panda Eye Sign

https://en.wikipedia.org/wiki/Raccoon_eyes#/media/File:Bilateral_periorbital_ecchymosis_(raccoon_eyes).jpg last assessed 27/9/2014

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CSF Rhinorrhoea

http://care.american-rhinologic.org/csf_leaks last assessed 27/9/2014

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Cervical spine immobilisation

Attempt full cervical spine immobilisation for patients who have sustained a head injury and present with any of the following risk factors unless other factors prevent this:GCS less than 15 on initial assessment by the healthcare professional.Neck pain or tenderness.Focal neurological deficit.Paraesthesia in the extremities.Any other clinical suspicion of cervical spine injury.

Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults, National Institute for Health and Clinical Excellence, January 2014.

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Spine immobilised in a neutral position on a long spinal board

C. R. G. Quick et.al. Essential Surgery - Problems, Diagnosis and Management, 5th Edition. Elsevier, 2014.

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Examination of the whole patient in headinjury•Cervical spine injury is common in patients with head injuries.

•Even obtunded patients should move all four limbs.

•Check and record power, tone and sensation in the peripheral nerves.

•Log roll to check the whole spine for steps and tenderness.

•Perform a rectal examination to check for anal tone and anal wink.

•Check for priapism.


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Neurologic AssessmentGCS scoreBrainstem examination – Pupillary examination, ocular movement examination, corneal reflex, gag reflexMotor examinationSensory examinationReflex examination

C. R. Ainsworth, Head Trauma, Medscape, Jan 09, 2015. (http://emedicine.medscape.com/article/433855, last accessed Sept 29, 2015)

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Glasgow Coma Scale (GCS) (Teasdale and Jennett, 1974)•severe head injury GCS score is 3 to 8,

•moderate head injury GCS score is 9 to 12,

•mild head injury GCS score is 13 to 15.

F. C. Brunicardi et al. Schwartz's Principles of Surgery, 10th Edition. McGraw-Hill Education, 2015.

Brain Herniation•1 subfalcine herniation

•2 midline shift

•3 uncal herniation

•4 central transtentorial herniation

•5 tonsillar herniation

30N. S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.

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Pupillary examinationEssential at the initial clinical assessment and during further observation. ↑ICP temporal lobe herniation compression of the 3rd nerve pupillary dilatation (initially on the side of the raised pressure) Remain reactive to light become sluggish fail to respond to light As the ICP increases same process on the contralateral side. Direct trauma to the eye traumatic mydriasisThe dilated pupil should not be confused with that due to a 3rd nerve palsy.


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Motor examinationDifficult to perform.Limited to an assessment of asymmetryDifference in muscle tone between the left and right sides. Indicative of a hemispheric injury and raises the possibility of a mass lesion.


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Sensory examinationAsymmetric response to central pain stimulation Often difficult.Unable to cooperate with sensory testing.Findings not reliable in patients who are intoxicated or comatose.


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Peripheral reflex examinationIdentify gross asymmetry in the neurologic examination.Indicate the presence of a hemispheric mass lesion.


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Classification According toScalp: open and closedSkull site: vault and base of skullSkull type: linear, comminuted and depressedIntracranial bleeding: extradural, subdural, subarachnoid and intraparenchymalBrain tissue causes: diffuse, blunt (direct, coup–contrecoup) and penetrating


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Management•Scalp wounds need closure.

•Significant depressed fractures need elevating, antibiotics and antiepileptics.

•Skull base fractures may be associated with CSF leak.

•Pneumococcus vaccination is valuable, but prophylactic antibiotics are not usually indicated.


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Criteria for performing a CT head scan

For adults, CT head scan within 1 hr of the risk factor being identifiedGCS <13 on initial assessment in the emergency department.GCS <15 at 2 hrs after the injury on assessment in the emergency department.Suspected open or depressed skull fracture.Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).Post-traumatic seizure.Focal neurological deficit.More than 1 episode of vomiting.


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Criteria for performing a CT head scan

For adults, CT head scan within 8 hr of the head injury:Age 65 yrs or older.Any history of bleeding or clotting disorders.Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).> 30 min retrograde amnesia of events immediately before the head injury.


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MRI•Limited role in the evaluation of acute head injury.

•Extraordinary anatomic detail, but

•Long acquisition times

•Difficulty in obtaining MRIs in persons who are critically ill

•Used in the subacute setting patients with unexplained neurologic deficits.

not commonly used to evaluate acute head injuries


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Investigating injuries to the cervical spine

CT cervical spine scan within 1 hour of the risk factor being identified:GCS < 13 on initial assessment.The patient has been intubated.Plain X-rays are technically inadequate.Plain X-rays are suspicious or definitely abnormal.A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).The patient is having other body areas scanned for head injury or multi-region trauma.


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Investigating injuries to the cervical spine (cont.)The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:◦ age 65 years or older◦ dangerous mechanism of injury (fall from a height of greater than 1 metre or

5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)

◦ focal peripheral neurological deficit◦ paraesthesia in the upper or lower limbs.


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Standard skull X-ray ‘Do not use plain X-rays of the skull to diagnose significant brain injury without prior discussion with a neuroscience unit.*

However, they are useful as part of the skeletal survey in children presenting with suspected non-accidental injury.*’

With the advent of NICE guidelines, CT investigation of choice for the diagnosis of clinically significant head injury. ^ Skull radiographs little role in the diagnosisMay be indicated in some instances, for eg. suspected non-accidental injury in children or lack of access to CT. ^

* Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults, National Institute for Health and Clinical Excellence, January 2014.

^ C. R. G. Quick et.al. Essential Surgery - Problems, Diagnosis and Management, 5th Edition. Elsevier, 2014.

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Standard skull X-ray views•Towne’s view from a 19-year-old woman after a blunt blow to the side of the head; she was fully conscious.

•This shows a depressed fracture in the left parietal bone (arrowed).

•The segment of bone is depressed by more than the thickness of the skull and therefore needed surgically elevating.


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Standard skull X-ray views•This 24-year-old woman suffered a high impact speed road traffic accident (RTA) and was admitted to hospital deeply unconscious and with deep scalp lacerations.

•Her GCS was 5.

•This AP X-ray shows extensive fractures (arrowed) in the parietal, occipital and squamous temporal bones.

•Because of the lacerations, these fractures were considered compound.


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Involving the neurosurgical departmentDiscuss with a neurosurgeon the care of all patients with new, surgically significant abnormalities on imaging. The definition of 'surgically significant‘ should be developed by local neurosurgical centres and agreed with referring hospitals, along with referral procedures.


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Indications for surgery Although no strict guidelines exist for defining surgical lesions in persons with head injury, most neurosurgeons consider any of the following to represent indications for surgery in patients with head injuries: extra-axial hematoma with midline shift > 5 mmintra-axial hematoma with volume > 30 mLan open skull fracturea depressed skull fracture with > 1 cm of inward displacementany temporal or cerebellar hematoma that is > 3 cm in diameter


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Involving the neurosurgical departmentRegardless of imaging, other reasons for discussing a patient's care plan with a neurosurgeon include:◦ Persisting coma (GCS 8 or less) after initial resuscitation.◦ Unexplained confusion which persists for > 4 hrs.◦ Deterioration in GCS score after admission (greater attention should be paid

to motor response deterioration).◦ Progressive focal neurological signs.◦ A seizure without full recovery.◦ Definite or suspected penetrating injury.◦ A CSF leak.


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Transfer from hospital to a neuroscience unit

Intubate and ventilate all patients with GCS 8 or less requiring transfer to a neuroscience unitComa Loss of protective laryngeal reflexes.Ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 13

kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa).Spontaneous hyperventilation causing PaCO2 < 4 kPa.


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Types of post-traumatic intracranial bleeding


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Extradural haemorrhageRadiology: 70% temporoparietal, 90% with fractures and underlying middle meningeal artery injury• Lenticular, convex shape• May have delayed enlargement• Rarely associated with other brain injury (in comparison to acute subdural hematoma)

Outcome: 5% mortality , 10–30% delayed enlargementPresentation: Most have history of severe head trauma• Classically have a “lucid interval” with resolving confusion after initial injury and then

neurological decline (actually occurs in < 30%)

Treatment: Surgical evacuation versus observation (if small and asymptomatic)


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Position of the haematoma if a CT scan has not been performed

i. it underlies the fracture (that may have been seen on the skull X-ray)

ii. it underlies a boggy swelling on the skull

iii. it is on the same side as the pupil that dilated first

iv. in 85% of cases it is on the contralateral side to the hemiparesis


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A large left extradural haematoma•biconvex shape

•exerts a mass effect

•a smaller right acute subdural haematoma is also evident.


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Exposure•A surgical temporal bone exposure showing a linear skull fracture

•with underlying extradural haematoma visible through a burr hole.


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Right frontal intracerebral haematoma•Extending into the lateral ventricle is evident.

•There is a small right posterior extradural haematoma, and traumatic subarachnoid bleeding in the sulci of the right hemisphere.


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Subdural haemorrhage•Epidemiology: Occurs in 15% of severe head trauma• Chronic subdurals are often seen in elderly with minor trauma especially when on

anticoagulation• Predisposition with conditions that cause brain atrophy and therefore, increased tension on

bridging veins (e.g. alcohol abuse, dementia)

•Etiology: Shear injury to bridging cortical veins (e.g., trauma, intracranial hypotension, severe atrophy, birth trauma)

•Radiology (CT):• Acute → hyperintense (can be isointense with low hematocrit or rapidly expanding lesions)• Subacute → isodense• Chronic (> 3 wks) → hypodense


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Subdural haemorrhage•Treatment: Patients with symptomatic SDH with midline shift should be surgically evacuated• Acute SDH requires a trauma craniotomy; chronic SDH may be amenable to evacuation with

burr holes

•Outcome: 35–90% mortality, depending on chronicity, patient age, and comorbidities• Reaccumulation of chronic SDH occurs in up to 45%


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Right-sided acute subdural haematomaThe substantial midline shift reflects brain swelling as well as bleeding: this is a high energy injury.

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Bilateral subdural haematomas•the left is mixed density,

•the hypodense material representing old blood and

•the higher density indicating more recent bleeding, probably loculated so requiring a craniotomy to evacuate.

•The bleed on the right is isodense, indicating intermediate age.


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Mechanisms of brain injury•The mechanism of ‘coup’ or direct injury is similar to a deceleration injury.

•A ‘contre-coup’ injury affects the side opposite to the blow because of rebound (horizontal section).

•In rotational injury the inertia of the brain suspended within the cranium leads to the tearing of surface vessels and subdural haemorrhage (horizontal and sagittal sections)


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Types of brain injury•Apparent traumatic subarachnoid haemorrhage may actually be a spontaneous subarachnoid haemorrhage which then led to the fall.

•Diffuse axonal injury results from high energy injury.

•Carotid dissection may be a delayed complication of skull base fracture.

•Non-accidental injury in children: beware delayed presentation.


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Severe bilateral contusions•Severe bilateral contusions

•in the basal aspect of the frontal lobes,

•caused by the brain moving over the rough, irregular skull base

•during sudden cranial acceleration.

F. C. Brunicardi et al. Schwartz's Principles of Surgery, 10th Edition. McGraw-Hill Education, 2015.

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Secondary Brain Injury Brain swelling and mass lesions raised intracranial pressure compromises perfusion secondary brain injury & further swelling.


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Further management of severe head injury•CT scan shows an intracranial haematoma shift of the underlying brain structures evacuated immediately.

•No surgical lesion, or following the operation:Careful observation using a chart with the GCS.Measures to decrease brain swelling:

careful management of the airway adequate oxygenation and ventilation. Hypercapnia cerebral vasodilatation brain swelling

elevation of the head of the bed 20°fluid and electrolyte balance.

NutritionRoutine care of the unconscious pt including bowel, bladder and pressure care.


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More aggressive methods to control intracranial pressureAdvisable if:

neurological state continues to deteriorate & the CT scan shows evidence of cerebral swelling without an intracranial haematoma

posturing (decerebrate) response to stimuliGCS < 8.

Intracranial pressure monitor should be inserted to assess the intracranial pressure as accurately as possible.Following the insertion, patient will be transferred to the intensive care department


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Intracranial pressure monitor

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More aggressive methods to control intracranial pressure

Controlled ventilation (PaCO2 at 30–35 mmHg) (↓PaCO2 ↓cerebral vasodilatation ↓ ICP)

CSF drainage from a ventricular catheter

Diuretic therapy (mannitol or frusemide)

Barbiturate therapy


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Care of other systems•Cardiovascular: Maintain SBP > 90 < 160 (depending on baseline blood pressure and ICP), place arterial line and central line

•Pulmonary: Intubation if required

•Gastrointestinal: Stomach ulcer prophylaxis (e.g. PPI)

•Genitourinary: Place Foley catheter (monitor urine output)

•Hematologic: Check CBC, type and cross

•Infectious disease: Consider antibiotic prophylaxis if a bolt or external ventricular drain (EVD) is in place; tetanus, hemophilus, pneumococcus vaccine if indicated


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Care of other systems•Fluids/electrolytes/nutrition: NPO, isotonic saline (0.9% NaCl) with goal of euvolemia, check electrolytes, mannitol to temporize elevated ICP for refractoryintracranial hypertension (to be held for serum osm > 320), hypertonic saline(goal of Na > 145)

•Musculoskeletal: Ensure adequate tertiary survey, maintain cervical spineprecautions until appropriately cleared

•Disposition: ICU


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Discharge criteria in minor and mild head injuryGCS 15/15 with no focal deficitsNormal CT brain if indicatedPatient not under the influence of alcohol or drugsPatient accompanied by a responsible adultVerbal and written head injury advice: seek medical attention if:

• Persistent/worsening headache despite analgesia• Persistent vomiting• Drowsiness• Visual disturbance• Limb weakness or numbness


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Outcomes of a head injury•Post-concussion syndrome gives persisting headaches and problems in concentrating.

•Players concussed when playing sport should not return immediately to the field.

•Good recovery is not necessarily a return to normal; it may be independent living.


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Neurological Complications•focal neurologic deficits

•global neurologic deficits

•seizures

•CSF fistulae

•hydrocephalus

•vascular injuries

•infections

•brain death


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Glasgow Outcome Score (GOS) (Jennett and Bond, 1975)

K. I. Bland et al. General Surgery, Principles and International Practice, 2nd Edition. Springer, 2009.

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Thank you very much!!! ^^Any questions???

Health & Medicine

Head injury