HEAD TRAUMA AND
MANAGEMENT
Dr. AMIT ROY
DNB SURGERY JR1
CENTRAL HOSPITAL DHANBAD
LEARNING OUTCOMES
● Types of head injury
● Difference between primary & secondary brain
injury
● Explain about the medical & surgical
management of mild , moderate , severe head
injury
● Describe about Extradural haematoma,
DEFINITION
● Head injury is defined as
traumatic injury involving
the cranium And
intracranial structures i.e
scalp ,skull , brain .
SURGICAL ANATOMY
EPIDEMIOLOGY
● Head injury continues to be an enormous public health
problem,even with modern medicine in the 21st century
.
● It is one of the most common cause of admission in
emergency Department worldwide .
● The most common cause include Motor vehicle
accident, falls, assaults, Sports related injuries, and
penetrating trauma.
PATHOPHYSIOLOGY
● Brain is contained within the skull, a rigid and
inelastic container . Hence only small increase in
volume within the intracranial compartment can be
tolerated before Pressure within the compartment
rises dramatically
● A second crucial concept in traumatic brain injury is
Cerebral Perfusion Pressure (CPP) , Which is the
difference between the Mean Arterial Pressure (MAP)
CLASSIFICATION – ACCORDING TO
● Types of injury - Open / Closed or Blunt
/ Penetrating
● Site of injury
● Pathology of injury
● Severity Of injury
OPEN INJURY CLOSED
INJURY
BLUNT HEAD INJURY
● A moving Head strikes a fixed
object or a moving object strikes an
immobile head 》 scalp injury, skull
fracture, contusion of brain
● Injuries resulting from rapid
deceleration of thehead causing
the brain to move within the cranial
cavity and come into contact with
bony protuberances within the skull
PENETRATING INJURY
● Low velocity injury : ● High velocity injury :
knives/arrow/screwdrivers bullets
SITE OF INJURY
SCALP INJURY
Laceration Subgaleal Hematoma
SKULL INJURIES – FRACTURS
Open fracture Closed fracture
SKULL INJURIES
1. CLOSED FRACTURE
A closed fracture has a significant chance of
associated intracranial haematoma
2. OPEN FRACTURE
● Open fracture has potential for serious infection
● Cover It lightly with the sterile dressing that
moistene with asterile
BASILAR FRACTURES
BRAIN INJURIES
PRIMARY SECONDARY
It is initial damage that occurs It is the result of neurophysiological
IMMEDIATELY as result of trauma and anatomic changes which occurs
from MINUTES TO DAYS after the
● Cerebral concussion trauma
● Cerebral contusion
● Cerebral laceration ● Cerebral edema
● Diffuse axonal Injury ● Intracranial haematoma
● Brain herniation
● Cerebral ischaemia
● Infection
PRIMARY BRAIN INJURY
1. CEREBRAL CONCUSSION is slight distortion causing temporary
physiological changes leading to transient loss of consciousness with
complete recovery
2. CEREBRAL CONTUSION is more severe degree of damage ith
bruising and cerebral oedema leading to diffuse or localized changes.
3. CEREBRAL LACERATION is tearing of brain surface with collection of
blood in different spaces and with displacement of dural Parts.
4. DIFFUSE AXONAL INJURY is a type of brain damage due to result of
mechanical shearing following deceleration, causing disruption and
《 DIFFUSE AXONAL INJURY 》
《 CONTUSION 》
INTRACRANIAL VASCULAR INJURY
● Extradural haematoma
● Subdural haematoma
● Sub-Arachnoid haematoma
● Intracerebral haematoma
EXTRADURAL HAEMATOMA – EDH
● Haematoma in Extradural
space
● Common site - Temporal
region
● Tear of middle meningeal
artery
● Commonly presents with
“lucid interval” / feature of
increased ICP
● CT Scan - lentiform ( lens
shaped or biconvex )
hyperdense lesion
SUBDURAL HAEMATOMA – SDH
● Haematoma between dura and
brain
● Occurs as a result of tearing of
cortical veins & due to cortical
laceration
● A SDH usually present with an
Loss Of consciousness from the
time of injury and progressive
● Clinical features are – headache,
cognitive decline, focal
neurological deficits & seizures
● CT Scan – Concavo-convex
lesion
SUB-ARACHNOID HAEMORRHAGE –
SAH
● Haematoma in the space between
the arachnoid space and the pia
matter which is a [ Sub-Arachnoid
Space ]
● May be spontaneous / trauma
● Spontaneous – Intracranial
Aneurysm
● Features of increased ICP
● Investigation –CT Scan , Angiogram
● Treatment including Clipping,
INTRACEREBRAL HAEMATOMA –
ICH
● Haematoma is formed
within the brain
parenchyma
● Due to areas of contusion
coalescing into a
contusional Haematoma
● CT-Scan appear as
hyperdense lesions with
associated mass effect and
EFFECT OF BRAIN INJURY
● BRAIN OEDEMA is accumulation of fluid, both intracellular &
extracellular. It is due to congestion & dilatation of blood
vessels, it maybe diffuse or localized.
● BRAIN NECROSIS is of severe variety with destruction and is
due to hemorrhagic infarction.
● BRAIN ISCHAEMIA is due to increased pressure, this can
lead to alteration in the perfusion of brain which itself
aggravatesthe ischaemia & this forms a vicious cycle,causing
progressive diffuse ischaemia of brain.
COUP AND CONTRE-COUP INJURIES
● COUP INJURY
occurs on the side of
the blow to the head .
● COTRE-COUP
INJURY occurs on the
side opposite to the
blow on the head
CONING
● It is due to increase ICP causing either :
1. Herniation of contents of supratentorial
compartment through the tentorial hiatus OR
2. Herniation of the contents of infratentorial
compartment through the foramen magnum
● In SUPRATENTORIAL HERNIATION, there is
compression of ipsilateral III Cranial nerve &
midbrain
● In INRFRATENTORIAL HERNIATION, there is
obstruction of cerebral aqueduct with damage to
CLINICAL APPROACH
1. HISTORY
2. EXAMINATION
HISTORY TAKING
● Mechanism of injury
● Loss of consciousness or amnesia
● Level of consciousness at scene and on
transfer
● Current symptoms / evidence of seizures
● Probable hypoxia or hypotension
● Pre-existing medical conditions
EVALUATION
1. ATLS Guidelines
2.ABCDE Approach
3. Resuscitation And
Primary Survey
4. Neurological
Assessment
5. Secondary Survey
EXAMINATION
NEUROLOGICAL ASSESSMENT
● Level of consciousness
● Glasgow coma scale
● Pupillary reaction to light and size
● Vital sign
● Reflexes
● Limb movements – normal / mild weakness / severe
weakness / spastic Flexion / Extension / no response
EXAMINATION
SECONDARY SURVEY
● Status and protection of airways
● General assessment and other injuries like
fractures, abdominal organ injuries,
thoracic injuries are looked for
● Presence of any scalp haematoma,
fractures of skull bone which may be
depressed has to be looked For
● Any blood from nose or ear , CSF
rhinorrhoea Or CSF otorrhoea has to be
GLASGOW COMA SCALE (GCS)
MILD -
13 TO 15
MODERATE -
9 TO 12
SEVERE -
3 TO 8
INVESTIGATIONS
● Basic tests
● X-Ray skull : to look for fracture, relative position of the
calcified pineal gland.
● CT scan : Plain (not contrast) to look for cerebral
oedema , haematomas , midline shift, Fractures,
ventricles, brainstem injury.
● Carotid arteriography/ MRI scan
● Investigations for other injuries like ultrasound oof
abdomen.
ICP – MONITORING
CRITERIA FOR HOSPITALIZATION
● Any altered level of consciousness
● Skull fracture
● Focal neurological features
● Persistent headache, vomiting, systolic hypertension,
bradycardia
● No CT - scan available or abnormal CT head
● Alcohol intoxication
● Bleeding from ear or nose
● Associated injuries
TREATMENT - MILD HEAD INJURY [ 14-
15 GCS]
Discharge - Criteria NICE Guidelines–CT Scan
● GCS – 15/15 ● GCS <13 at any point
● NO Focal neurological ● GCS 14 or 14 at 2 hours
deficit ● Focal neurological deficit
● Follow up in A and E ● Suspected Open, depressed,
department or basal skull fracture
● Seizure
● Vomiting > one episode
TREATMENT - MODERATE TO SEVERE
INJURY
AIM
● Prevention of hypoxia
● Control of ICP
● Maintenance of
Perfusion
● Others
CONTROL OF ICP – MEDICAL
# Normal ICP = 8 -12 mm Hg
● Position head up 30°
● Avoid obstruction of venous drainage of head
● Sedation +/– muscle Relaxant
● Normocapnia 4.5 to 5.0 kPa
● Diuretics : furosemide , mannitol
● Seizure control
● Normothermia
● Sodium balance
● Barbiturates
CONTROL OF ICP – SURGICAL
● Early evacuation of
focal Haematomas :
EDH , SDH (Burr hole /
Craniotomy)
● CSF drainage via
ventriculostomy
● Delayed evacuation of
swelling contusions
● Decompressive
Craniectomy
EARLY COMPLICATIONS
● Brainstem injury due to coning
● Compression over Cerebellum and medulla
● CSF rhinorrhoea / CSF leak
LATE COMPLICATIONS
● Chronic Subdural Haematoma
● Early post traumatic epilepsy
● Late post traumatic epilepsy is due to scarring
and gliosis of Cerebrum
● Post traumatic Amnesia
● Post traumatic hydrocephalus
● Post traumatic headache
SUMMARY OF “ TBI “
MANAGEMENT
STEPS RATIONALE
Respiratory support [intubation & ventilation] Comatose ,unable to protect airways
Elevate head 30° to 40 ° Facilitate venous drainage
Straighten neck, no tape encircling the neck Facilitate venous drainage
Avoid hypotension ( SBP < 90 mmHg ) Prevent hypoxia
Control hypertension Avoid transmission of pressure to ICP
Avoid hypoxia ( PaCO2 < 60 mmHg ) Prevent vasodilation
Control ventilation, aims PaCO2 35 - 40 mmHg Avoid vasoconstriction / dilatation
Adequate sedation To reduce brain metabolism
Do CT Brain Ascertain intracranial Pathology rapidly
that life should be despaired of”
THANK
