EVALUATION OF A PATIENT WITH HEAD INJURY

DR. BARUN KUMAR

Epidemiology

• Estimated 5-10 lakh cases of head injury every year

• 20% moderate to severe

• 1.5 lakh trauma deaths

• 50% attributable to head trauma

Initial assessment

• The initial management is in accordance to ATLS guidelines.

• A - airway• B - breathing• C - circulation

Airway

• Manual manoeuvres (chin lift, jaw thrust,recovery position, etc.)

• Insertion of oral or nasal airway • Use of suction • Assisted ventilation using bag–valve–mask• Endotracheal intubation • Cricothyroidotomy (with or without

tracheostomy)

Airway

• Goals

• Maintain SPO2 > 90%

• Maintain PaO2 > 60mmHg

• Indication for intubation

Indication for intubation

Unable to maintain airway

GCS ≤ 8Loss of protective laryngeal reflexesUnstable facial bone # Bleeding into mouthSeizures

Ventilatory insufficiency Spontaneous hyperventilationIrregular respiration

Breathing

• Assessment of respiratory distress and adequacy of ventilation

• Administration of oxygen • Needle thoracostomy • Chest tube insertion

Circulation

Goals

• Maintain SBP > 90mm of Hg

• Prevention of secondary brain injury

Circulation

• IV crystalloid• Hypotensive resuscitation • Colloid• Blood • Component transfusion

• Transport to equipped center

• Prognosis depends on initiation of primary care

• Enroute management

Neurological assessment

• Glasgow coma scale --Quick ,efficient • Examination of Pupil • history

Classification by clinical severity

• Mild/Minor TBI: GCS 13-15; mortality 0.1%

• Moderate TBI: GCS 9-12; mortality 10%

• Severe TBI: GCS <9; mortality 40%.

Pupil

Pupil size:

• The normal diameter of the pupil is between 2 and 5 mm, and although both pupils should be equal in size,• a 1-mm difference is considered a normal

variant.• Abnormal size is noted by anisocoria: >1 mm difference between pupils

Pupil

Pupil symmetry:

• Normal pupils are round, but can be irregular due to ophthalmological surgeries.

• Abnormal symmetry may result from compression of CNIII can cause a pupil to initially become oval before becoming dilated and fixed.

Pupil

Direct light reflex:

• Normal pupils constrict briskly in response to light, but may be poorly responsive due to ophthalmological medications.

• Abnormal light reflex may be seen in sluggish pupillary responses are associated with increased ICP• A non-reactive, fixed pupil has <1 mm response to

bright light and is associated with severely increased ICP.

History Mechanism of injury and detailed description of the injury • loss of consciousness, amnesia, lucid periods • seizures, confusion, deterioration in mental status • vomiting or headache

Drug or alcohol use • current intoxication: shown to have an increased association with intracranial injury detected on CT[89] • chronic: associated with cerebral atrophy, thought to increase risk of shearing of bridging veins

• Past medical history, including any CNS surgery, past head trauma, haemophilia, or seizures• • Current medications including anticoagulants• Age: TBI in older age has a poorer outcome in all subgroups

Physical examinationHead and neck

• inspection for cranial nerve deficits, periorbital or postauricular ecchymoses, CSF rhinorrhoea or otorrhoea,haemotympanum (signs of base of skull fracture)

• fundoscopic examination for retinal haemorrhage (sign of abuse)[90] and papilloedema (sign of increasedICP)

• palpation of the scalp for haematoma, crepitance, laceration, and bony deformity (markers of skull fractures)

Physical examination

• auscultation for carotid bruits (sign of carotid dissection)

• evaluation for cervical spine tenderness, paraesthesias, incontinence, extremity weakness, priapism (signs of spinal cord injury)

• Extremities should receive motor and sensory examination (for signs of spinal cord injury)

Baseline laboratory investigations should include:

• CBC including platelets• serum electrolytes and urea• serum glucose• coagulation status: PT, INR, activated PTT• blood alcohol level and toxicology screening if indicated

Indications for CT scan • eye opening only to pain or not conversing (GCS 12/15

or less)

• confusion or drowsiness (GCS 13/15 or 14/15) followed �by failure to improve within

• at most one hour of clinical observation or within two hours of injury (whether or not intoxication from drugs or alcohol is a possible contributory factor)

• base of skull or depressed skull fracture and/or �suspected penetrating injuries

Indications for CT scan • a deteriorating level of consciousness or new focal �

neurological signs

• full consciousness (GCS 15/15) with no fracture but �other features, eg

- severe and persistent headache- two distinct episodes of vomiting

• a history of coagulopathy (eg warfarin use) and loss of �consciousness, amnesia or any neurological feature.

Referral • Any evidence of major brain trauma should be managed at a

trauma center and a neurosurgeon.

Indications for referral

• GCS<15 at initial assessment for two hours and refer if GCS score remains<15 after this time)

• post-traumatic seizure (generalised or focal)�• focal neurological signs�• signs of a skull fracture (including cerebrospinal fluid from �

nose or ears,haemotympanum, boggy haematoma, post auricular or periorbital bruising

• loss of consciousness�• severe and persistent headache�• repeated vomiting (two or more �

occasions)• post-traumatic amnesia >5 minutes�• retrograde amnesia >30 minutes�• high risk mechanism of injury (road traffic �

accident, significant fall)• coagulopathy, whether drug-induced or �

otherwise.

TRAUMATIC BRAIN INJURY

Bone fracture Intracranial hemorrhage

Diffuse axonal injury

Open/ closed

Linear/ comminuted

Depressed/ nondepressed

EDH SAH Intraparenchymal hemorrhage

ASSESSMENT OF INTRACRANIAL PRESSURE

CPP = MAP – ICP

CPP = cerebral perfusion pressure

>70mmHg in adult> 60mmHg in children

ICP= Intracranial pressure Range 5mmHg (infant) to 15mmHg (adult)

ASSESSMENT OF INTRACRANIAL PRESSURE

ICP should be monitored in :

• Severe head trauma (GCS= 3-8 )

• Abnormal CT scan ( hematoma, contusion, swelling , herniation, compressed basal cistern)

• A ventricular catheter connected to an external strain gauge transducer

• Alternative- intraparenchymal transducer

GOALS

• ICP < 20 mm of Hg

• CPP > 70 mm of Hg ( < 50 is critical )

FURTHER MANAGEMENT

• HYPOXIA• HYPEROSMOLAR THERAPY • HYPOTHERMIA• NUTRITION • ANTISEIZURE • HYPERVENTILLATION • ANTIBIOTICS • ANALGESIA

Refrences 1. Sabiston textbook of surgery 19th edition 2. Bailey & love’s short practice of surgery 26th ed3. BMJ, best practice assessment of head trauma, acute4. Guidelines for the management of severe traumatic brain injury –

BRAIN TRAUMA FOUNDATION 5.GUIDELINES FOR ESSENTIAL TRAUMA CARE World Health Organization Avenue Appia 201211 Geneva 276.NICE guidelines head injury 7.The Brain Trauma Foundation. Prehospital Emergency Care8.The Brain Trauma Foundation. Early indicators of Prognosis in Severe Traumatic Brain Injury.9.The Brain Trauma Foundation. Surgical Management of TBI Author Group.

Thank you