HEAD INJURIES

Submitted To:- Submitted By:-

Dr. Sandeep Singh Jasmine Kaur
Navdeep Kaur
HEAD INJURY
• It is any trauma to the scalp, skull or brain.
• It ranges from mild bump or bruise to a traumatic brain injury
• Traumatic Brain Injury (TBI) is an insult to the brain due to any
external force leading to permanent or temporary impairment of the
cognitive, physical, emotional and behavioral functions, with an
altered state of consciousness
INCIDENCE:-
• Common among adolescents, young adults (less than 25 years old)
and older adults (65 years old or above)
• 50% deaths are due to TBI

ETIOLOGY:-
• Motor vehicle accidents
• Falls
• Physical assaults
• Sports – related injuries
MECHANISM OF INJURY
• It is caused due to any external force
• Open head injury – When the injury is associated with skull
fracture it is known as open head injury
• Closed head injury – When the injury occurs without any
skull fracture it is known as closed head injury
PATHOPHYSIOLOGY
• The brain damage can be categorized into primary and
secondary damage
• Primary damage – It results from either brain tissue coming
into contact with an object or rapid acceleration/
deceleration of the brain
- Contact injuries results in contusions, lacerations and
intracerebral hematomas
- Acceleration/deceleration cause diffuse axonal injury (DAI)
and intracerebral hemorrhages
DIFFUSE AXONAL INJURY (DAI):-
-It leads to axonal degeneration occurring after mild,
moderate or severe TBI
-It is common in high-speed motor vehicle accidents and in
some sports related TBI
-Depending on the severity of the injury, effects may range
from mild coma to death
• Secondary Damage - It results from biochemical, cellular, and
molecular events that evolve over time due to the initial
injury and injury-related hypoxia, edema
 TYPES OF HEAD INJURY

Scalp Laceration Skull Fracture Minor Head Trauma Major Head Trauma

Acc. to fracture
Acc. to location
type

-Linear -Temporal
-Depressed -Parietal
-Comminuted -Orbital
-Compound
SCALP LACERATION
• Most minor type of head trauma
• Easily recognized
• Scalp is highly vascular so profuse bleeding occurs
SKULL FRACTURES
ACCORDING TO FRACTURE TYPE:-
1. Linear – Break in the continuity of the bone without alteration of
related parts, occurs mainly due to low velocity injuries
2. Depressed- It is inward indentation of the skull caused due to
powerful blow
3. Comminuted- It is multiple linear fractures with fragmentation of
bones into several pieces
4. Compound- Also known as open fracture where there is scalp
laceration and splintering of the skull bone
*ACCORDING TO THE LOCATION:-
1. Temporal Bone Fracture-
• Battle’s sign- Oval shaped bruising over the mastoid behind the ear
• It may take 24-48 hours to develop

2. Parietal Bone Fracture-

• CSF otorrhoea
• Bulging of tympanic membrane by blood or CSF
• Deafness
3. ORBITAL BONE FRACTURE
• Periorbital ecchymosis
• Racoon eyes- Bruising limited to the orbital margins indicates blood
tracking from behind
MINOR HEAD TRAUMA
*CONCUSSION
• It is mild injury caused by direct or indirect blow to the head
• In this the brain suddenly shifts inside the skull and knocks against the
skull
• Brief disruption of LOC
• Symptoms may evolve over minutes or hours after the event
MAJOR HEAD TRAUMA
*CEREBRAL CONTUSION
• It is the bruising of the brain tissue within the focal area
• It is usually associated with closed head injury
• Coup-contrecoup injury is noted
• Contusion occurs at the site of direct impact of the brain on the skull -
Coup injury
• Contusion occurs on exactly opposite side of the brain from injury –
Contrecoup injury
*CEREBRAL LACERATIONS
• Cerebral lacerations are actual tearing of the brain tissues
• It occurs when an object or a piece of bone penetrates the skull
(causing a skull fracture) and tears brain tissue
• It is often associated with depressed, open fractures and penetrating
injuries
*HEMATOMA
• A hematoma is a blood clot within the brain or on its surface
• Types:-
- Epidural hematoma - Results from bleeding between the dura and the
inner surface of the skull
- Subdural hematoma – Results from bleeding between the dura mater
and arachnoid layer
EFFECTS ON BODY FUNCTIONS AFTER HEAD INJURY
1. Alteration is the State of Consciousness – The patient with
head injury may be found to be in:-
• Coma - complete arrest of all the cerebral function,
unresponsiveness to even strong noxious stimuli
• Stupor - state of generalized unresponsiveness but the
patient reacts to painful stimuli through some bodily
movements
• Delirium - when the patient comes out of the state of
unconsciousness he appears to be disoriented, fearful
2. Neuromuscular Impairments –
• Upper extremity and lower extremity paresis
• Abnormal tone
• Motor function
• Postural control

3. Cognitive Changes – Cognitive function of the patient may be

affected due to generalized or focal lesion. The patient may have:-
• Post traumatic amnesia - It is the time lapse between the injury
till the time when the patient is supposed to have recovered
back his memory function
• Retrograde amnesia – It is inability of the patient to recollect
events that took place just before the injury

4. Emotional Changes - The patient may have:-

• Euphoria
• Intolerance
• Irritability
• Inappropriate sexual behavior
• Unacceptable social or interpersonal behavior
CLINICAL ASSESSMENT
• Vital signs
• Basal skull fracture signs –
- Bilateral periorbital edema – Raccoon eyes
- Battle’s sign - Bruising over the mastoid
- CSF otorrhoea
- CSF rhinorrhea
• Conscious level – Glasgow Coma Scale (GCS)
- This scale measures level of consciousness and helps to classify the
severity of injury
- It is comprised of three response scores: motor response, verbal
response and eye opening response
*Classification:-
• Score of 8 or less –Severe brain
injury
• Score between 9 to 12 –
Moderate brain injury
• Score between 13 to 15 – Mild
brain injury
• Limb weakness - Determine limb weakness by comparing the response in each
limb to painful stimuli
- Hemiparesis or hemiplegia usually occurs in the limbs contralateral to the side of
the lesion
• Evaluation of pupil response
*INVESTIGATIONS :-
• CT Scan is done to evaluate cranio-cerebral trauma
• National Institute for Health and Clinical Excellence (NICE) guidelines to carry out
CT Scan:-
- IN ADULTS – the presence of :-
1. Glasgow coma score < 15, 2 hours from injury
2. Suspected open or depressed skull fracture
3. Sign of basal skull fracture
4. Post traumatic seizure
• In children, use a low threshold for immediate CT scanning
• MRI Scan – It is more sensitive than CT scan in detecting small lesions
• X-ray –
- X-ray of cervical spine because cervical spine injury may accompany
head injury
- Also X-ray of chest, abdomen, pelvis and limbs if required
Care and management of
head injury
INTERDISCIPLINARY TEAM
• Patients who are in persistent vegetative state
may receive ongoing therapy in nursing home.
But the patients who begin to recover from
coma with moderate to severe cognitive,
behavioral,and physical impairments often
continue rehabilitation with the help of
interdisciplinary team.
TEAM MEMBERS
1.MEDICAL SPECIALISTS
• Neurologist,Physician, Geriatrician, Orthopaedic Surgeon,
Neurosurgeon, Neuropsychiatrist, Endocrinologist,
Anaesthetist and Intensivist, Pain Management Doctor,
Ophthalmologist and others depends on an individual
person‘s needs.
2. PHYSIOTHERAPIST
Physiotherapist facilitates movements re-education, mobility
and balance retraining, verticalisation, general fitness and
one’s tolerance to being physically challenged; advise on
physical activity including access to leisure activities like
gym, swimming, golf, games, etc. to prevent other co-
morbidities and support inactivity, fatigue, mood and other
traumatic brain injury related issues’ management.
3.Occupational Therapist
Occupational Therapist facilitate independence in activities
of daily living (ADLs) like dressing, washing, cooking, leisure
activities, budgeting and planning; supports home
adaptations and environment organisation; facilitates
higher cognitive and executive functions retraining, driving
skills, vocational training and return to work; helps with
fatigue .
• 4.SPEECH AND LANGUAE THERAPIST
Speech and Language Therapist facilitates communication
skills re-education including understanding and expressing
both written and spoken language and improving speech
clarity; helps to identify any communication aids strategies
for effective communication at school, work, social network;
assess swallowing difficulties (dysphagia) and provide
guidance on safe swallowing management i.e.: type of diet,
5.REHABILITATION NURSE
• Role of nurse will be
1. Dispensing medications and closely monitoring their effects
2. Initiate a bowel and bladder retraining program to assist
the patient in learning to become continent again
3. Daily monitoring of vital signs to make sure that patient
remains medically stable
4. Inspect the patients skin daily to ensure there are no signs
of skin breakdown
6.Neuropsychologist
7.Case coordinator
EARLY MEDICAL MANAGEMENT
1.Early resuscitation at the scene of accident
2.Once the patient arrives at medical centre the primary goals are to
• minimize secondary brain injury by optimizing cerebral blood flow and
oxygenation
• Stabilize vital signs
• Perform complete examination, identify and treat any nonneurilogical injuries
• Continuously monitor the patient
• Systolic bp should be kept above 90 mmhg and oxygenation saturation above
90 percent
• Patient‘s neck should be stabilized with a collar and head elevated to 30 degree.
This is done to protect the spine in case of instability and to avoid increase in
Intracranial pressure.
• Elevated Intracranial pressure can be treated with the use of sedating
medications, moderate head up position.
Cervical collar
 MEDICATIONS
• Medications to limit secondary damage to the brain immediately after an injury
may include:
• Anti-seizure drugs. People who've had a moderate to severe traumatic brain
injury are at risk of having seizures during the first week after their injury.
• An anti-seizure drug may be given during the first week to avoid any additional
brain damage that might be caused by a seizure. Continued anti-seizure
treatments are used only if seizures occur.
• Coma-inducing drugs. Doctors sometimes use drugs to put people into temporary
comas because a comatose brain needs less oxygen to function. This is especially
helpful if blood vessels, compressed by increased pressure in the brain, are unable
to supply brain cells with normal amounts of nutrients and oxygen.
• Diuretics. These drugs reduce the amount of fluid in tissues and increase urine
output. Diuretics, given intravenously to people with traumatic brain injury, help
reduce pressure inside the brain.
SURGICAL INTERVENTION
Emergency surgery may be needed to minimize additional damage to
brain tissues. Surgery may be used to address the following problems:
1. Removing clotted blood (hematomas). Bleeding outside or within the
brain can result in a collection of clotted blood (hematoma) that puts
pressure on the brain and damages brain tissue.
2. Repairing skull fractures. Surgery may be needed to repair severe skull
fractures or to remove pieces of skull in the brain.
3. Bleeding in the brain. Head injuries that cause bleeding in the brain
may need surgery to stop the bleeding.
4. Opening a window in the skull. Surgery may be used to relieve
pressure inside the skull by draining accumulated cerebrospinal fluid or
creating a window in the skull that provides more room for swollen
tissues.
Physiotherapy
assessment and
management
 PHYSIOTHERAPY ASESSMENT
Physiotherapy assessment commences once the patient is medically
stable
• Information required before starting the
assessment;
1. State of consciousness of patient
2. Area of brain injured
3. Any other injuries sustained as in case of road traffic
accidents frequently also have a range of
musculoskeletal, abdominal and chest injuries
4. Any impact on cognition of patient – neuropschological
assessment is indicated
AREAS OF ASSESMENT
1. Arousal attention and cognition
2. Abnormal muscle tone
3. Abnormal posture :
• Decorticate posture ;upper extremities are in flexed posture and lower
extremities are extended
• Decrebrate posture; both upper and lower extremities are positioned in extension
1. Ventilation and respiration
2. Skin integrity
3. Sensory integrity
4. Motor function
5. Range of motion
6. Reflex integrity
GOALS FOR TREATMENT
• Physical function and level of alertness are increased.
• The risk of secondary impairments is reduced.
• Motor control is improved.
• The effects of tone are managed.
• Postural control is improved.
• Tolerance of activities and positions is increased.
• Joint integrity and mobility are improved or remain
functional.
• Family and caregivers are educated on patient’s diagnosis,
physical therapy interventions, goals, and outcomes.
• Care is coordinated among all team members.
 Physiotherapy Management divided
into three main sections
1. Physiotherapy management of severe to moderate
traumatic brain injury during acute stage
2. Physiotherapy management of severe to moderate
traumatic brain during active stage of rehabilitation
3. Physiotherapy management of mild traumatic brain injury
Categories of treatment technique
• Therapeutic exercises
• Manual therapy techniques like mobilisations or manipulations
• Prescription and application of equipment like orthotic or
prosthetic devices, mobility aid, wheelchair
• Airway clearance techniques
• Functional training in self-care (ADLs) and home care
• Functional training at work, school, play and leisure activities
including community reintegration
• Use of physical agents and other modalities use like hydrotherapy,
electrotherapy, cryotherapy
• Integumentary protective techniques enhancing tissue viability
• Discharge Planning
Physiotherapy management of
severe to moderate traumatic brain
injury during acute stage
1.RESPIRATORY CARE
• Positioning - to use gravity to aid sputum removal from
the lungs
• Manual and ventilator hyperinflation
• non-invasive ventilation
• Percussion, vibration, suctioning - all aim to aid removal
of sputum
• Respiratory muscle strengthening
• Breathing exercises and mobilisation
• Early mobilising via passive or active-assisted handling advised by
nursing and physiotherapy staff.
• Movement facilitation using neuro-developmental or
neuromuscular concepts
• Positoning on the bed in various postural sets including side- lying
and prone when appropriate and position changes every 2 hours.
• Positioning out of bed i.e.: in the wheelchair or specialist
supportive chairs to enhance early recovery and increased level of
alertness led by Physiotherapist
• Verticalization, i.e.: using a tilt table or with an increased number of
therapists (3-4) to ensure weight bearing and stimulate alertness.
• Splinting including serial casting with consideration of
communication, cognition and behaviour deficits and its impact on
safety and compliance.
• Sensory stimulation of auditory, olfactory, gustatory, visual, tactile-
kinesthetic and vestibular systems and environmental enrichment.
• Balance and postural control training like weight shift and midline
orientation activities when transferring and in side-lying or sitting.
Physiotherapy management of severe to
moderate traumatic brain injury during
stage of active rehabilitation
• Locomotion training with bodyweight support and overground practice.
• Locomotion’s supporting training of strength, sit-to-stand practice and
standing balance retraining.
• Cardio-vascular training with the use of equipment like cycle
ergometer or treadmill or circuit training.
• Range of motion and stretching exercises.
• Resistance training with generic principles but with consideration of
postural control impairment and relevant adjustments allowing safe
and efficient training.
• Sensory stimulation using various modalities including auditory,
olfactory, gustatory, visual, tactile-kinaesthetic and vestibular systems
and environmental enrichment.
• Functional electrical stimulation (FES) with limited evidence for long
term efficacy but good being adjunct generating repetitions and
supporting the quality of movement
• Use of various postural sets including crook position,
bridging, side lying, prone, 4-point kneeling, high
kneeling, sitting, perching, standing, step stance, prone
standing and others
• Dual tasking training supporting locomotion and balance
recovery or re-education using motor and cognitive
additional task.
• Education for patient / caregivers / family to enhance
understanding about cognitive deficits determining
movement acquisition, behaviour that challenge
management, safety principles of mobility and balance
practice using seminar format.
• Falls prevention with consideration of individual, task and
environment changing interventions with a multifactorial
approach addressing all balance components.
Physiotherapy management during
stage of mild traumatic brain injury
1. Prevention of post traumatic headache ; musculoskeletal based
interventions such as stretching, strengthening , manual therapy
and modalities can be used when appropriate for patients with
posttraumatic patients headache and temporomandibular disorder
2. Prevention of vestibular problems; If the patient has BPPV ( benign
paroxymal positional vertigo) Canalith repositioning treatment can
be performed in which patient’s head is moving into different
positions in specific sequence to move the debris out of the
involved semicircular canal back into the vestibule. Gaze
stabilization exercises are also involved.
3. Improve gait and balance
• Task oriented balance exercises
• Balance training that incorporates the use of different sensory
modalities such as standing on dense foam with eyes open and eyes
closed can be performed
4.Patient education
Depending upon patient’s symptoms and status patient can be taught
how to perform neck ROM , isometric strengthening exercises and
educate the patient about appropriate sleep posture
THANK YOU