Post on 26-Dec-2015
Adult Head Injury
Rajiv Sighamoney
Objectives
To have a knowledge and understanding of types of Head Injury (HI)
Epidemiology of HI
• 1,000,000 hospitalised /year as of result • Males 2-3 x more likely to suffer• Age group 15-29 mainly• 5 more males within this group
www.headway.org.uk
Cerebro-spinal fluid
Cerebral arterial blood flow
Types- Severity
• Minor – 150,000
• Moderate– Unconsciousness for 0-6hrs– Some have physical & psychological problems after 5 yrs– 10,000
• Severe HI– Unconscious 6+hrs– Of these only approx 15% return to work within 5yrs– 11,600
Types-open or closed
• Open– Penetrating– Low velocity (stab wound) – High velocity (Gun shot/Nail gun) – Resultant local damage to the brain and along the
tract
Open Head Injury – Skull Penetration
Types-open or closed
• Closed– Focal
• Direct blow to the head or from a fall • Assault 10%• Domestic incidents 20-30%• Sport 10-15%• Cycling - °helmet 20%
– Diffuse• RTA 40-50%• Acceleration-deceleration forces result in
shearing and contusion injury • Diffuse axonal injury
Types- Pathology
• Concussion– Usually reversible traumatic paralysis of
nervous function
• Contusion– Bruising or crushing without interruption of
physical continuity
• Diffuse axonal injury– Acceleration-deceleration forces result in
shearing and contusion injury
Coup and Contra-coup mechanism
Actual brain injury• Bruising
– Small blood vessels ruptured– Haematoma
• Tearing– May not be observed on CT/MRI
• Swelling– As a result of the normal response to injury – i.e. exudate, increased blood flow
Monro-Kellie hypothesis• The intact cranium & vertebral canal with
the relatively inelastic dura form rigid container
• ↑ in intracranial contents, viz, brain, blood or CSF will ↑ ICP
• If one of these three elements ↑ in volume it must be at the expense of the other two
Example of internal injury
Epidural haematoma Intra-cerebral haematoma
Factors increasing ICP
• Hypoxaemia/hypercapnia
• Worsening oedema, bleeding
• Pyrexia
• Anxiety, pain
• Positioning - tip & turn, head movements
• Cough
• Suctioning
Associated injuries• In polytrauma there may be
– chest wall injury and lung damage– multiple fractures– abdominal & pelvic injuries
• Major blood loss• Loss of consciousness resulting in
airway compromise
↓CRITICALLY ILL PATIENT
Non-traumatic head injuries
• CVA
• Sub-arachnoid haemorrhage
• Aneurysm
• Tumours
• Cerebral oedema
• Encephalopathy with electrolyte imbalance
Aims of medical management
• Treat 1° brain injury – Stop bleeding– Remove clots– Maintain adequate CBF Metabolic demands– Promote cerebral draining– Control ICP
• To prevent further 2° brain damage
Treatment
• Decompress–Craniotomy–Burr holes–Bone flap removal
• Dehydrate
• Drugs
• CSF drainage
GM AIM/ALERTPrinciples of assessment
• A (Airway) - Maintain airway
• B (Breathing) - Ventilate & Sedate (GCS<8)
• C (Circulation) - Monitor CVS
• D (Disability) - Neurological assessment
• E (Extremity) - Control fitting
Bibliography• Fewings, J. (1999) ‘Management of the
Acute Head Injury’, Royal Hallamshire Hospital, Sheffield, (Unpublished presentation).
• GM AIM (2003) ‘Greater Manchester Acute Illness Management’, Course Booklet. Greater Manchester Critical Care Skills Institute NHS.
• http://images.google.co.uk• http://www.headway.org.uk
Further reading• Adams, A., et al (1998). ‘Chapter 6 The
Intensive Care Unit’, In: M. Smith, & V. Ball, (1998), Cardiovascular / Respiratory Physiotherapy. London: Mosby, pp 73 – 117.
• Enright, S., (1992). ‘Cardiorespiratory effects of chest physiotherapy’, Intensive Care Britain, 1992, p118-123.