Head Injuries 1

7/28/2019 Head Injuries 1

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2012-2013

HHeeaadd IInnjjuurriieessPresented to Dr.Gehan MoussaPresented by Ahmed Wagdi


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Head Injuries

A head injury is any trauma that leads to injury of the scalp, skull, or brain.

The injuries can range from a minor bump on the skull to serious brain

injury.

Head injury is classified as either closed or open (penetrating).A closed head injury means you received a hard blow to the head

from striking an object, but the object did not break the skull.

An open, or penetrating, head injury means you were hit with anobject that broke the skull and entered the brain. This usually

happens when you move at high speed, such as going through the

windshield during a car accident. It can also happen from a

gunshot to the head.

Types of Head Injuries:Traumatic brain injuries are commonly categorized according to severity:

1)Mild Traumatic Brain Injury The most common type of brain injury(75%-85%) NO loss of consciousness or a brief (


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2)Moderate Brain Injury Loss of Consciousness /Coma between 20-30 minutes to 24 hours,

followed by a few days or weeks of confusion.

EEG/CAT/MRI is positive for brain injury. Patient with moderate brain injury have long-term with

difficulties (50%)

There is clear evidence that an injury has occurred.3)

Severe Traumatic Brain Injury Prolonged loss of consciousness or coma of days, weeks, or

longer.

80% of patient with severe brain injury have multiple impairmentsin functioning.

Patient requires weeks, months and years of therapy to regainskills and regain the function.

Progress may be very slow.


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Open Head Injuries

Is a head injury in which the Dura mater, the outer layer of theMeninges, is breached.

Penetrating injury can be caused by high-

velocityprojectiles or objects of lower velocity such as knives, or

bone fragments from a skull fracture that are driven into the

brain.

A perforating head injury is one in which the object passesthrough the head and leaves an exit wound. Head injuries caused

bypenetrating trauma are serious medical emergencies and may

cause permanentdisabilityordeath.

Mechanism of Injury Injury from high-velocity missiles, injuries may occur from initial

laceration and crushing of brain tissue by the projectile.

High-velocity objects create rotations and create a shock wavethat cause stretch injuries, forming a cavity that is 3 to 4 times

greater in diameterthan the missile itself.

The tissue that was compressed during cavitations remainsinjured.

Destroyed brain tissue may either be ejected from entrance orexit wounds or compression against the sides of the cavity

formed.
http://en.wikipedia.org/wiki/Head_injuryhttp://en.wikipedia.org/wiki/Dura_materhttp://en.wikipedia.org/wiki/Meningeshttp://en.wikipedia.org/wiki/Velocityhttp://en.wikipedia.org/wiki/Projectileshttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Penetrating_traumahttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Deathhttp://en.wikipedia.org/wiki/Lacerationhttp://en.wikipedia.org/wiki/Projectilehttp://en.wikipedia.org/wiki/Shock_wavehttp://en.wikipedia.org/wiki/Diameterhttp://en.wikipedia.org/wiki/Entrance_woundhttp://en.wikipedia.org/wiki/Exit_woundhttp://en.wikipedia.org/wiki/Exit_woundhttp://en.wikipedia.org/wiki/Entrance_woundhttp://en.wikipedia.org/wiki/Diameterhttp://en.wikipedia.org/wiki/Shock_wavehttp://en.wikipedia.org/wiki/Projectilehttp://en.wikipedia.org/wiki/Lacerationhttp://en.wikipedia.org/wiki/Deathhttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Penetrating_traumahttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Projectileshttp://en.wikipedia.org/wiki/Velocityhttp://en.wikipedia.org/wiki/Meningeshttp://en.wikipedia.org/wiki/Dura_materhttp://en.wikipedia.org/wiki/Dura_materhttp://en.wikipedia.org/wiki/Head_injury


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Low-velocity objects usually cause penetrating injuries in theregions of the skull's temporal bones ororbital surfaces, as bones

are thinner and more able to break.

Damage from lower-velocity penetrating injuries is restricted tothe tract of the stab wound, because the lower-velocity object

does not create as much cavitations.

Open head injuries differ depending on the type ofskull fracture, of which there are :

a)Linear Skull Fracture Linear skull fracture, or a crack in the skull, presents about 69%

percent of all open head injuries. Depending on the location of

the injury, patients with linear skull fractures may suffer a variety

of complications, including blood vessel damage and leakage of

cerebrospinal fluid from the nose and ears.

Patients with significant brain swelling may suffer from linearskull fractures as a result of the pressure on the skull.

b) Depressed Skull Fracture

Depressed skull fractures are often the result of a severe blow tothe head with a blunt object. Broken skull fragments from

depressed skull fractures penetrate or compress brain tissue and

can cause severe brain damage.

A depressed skull fracture occurs when a piece of skull is pushedtoward the inside of the skull. Surgery may be required to elevate

the depressed fragment.

Major causes of head injuries:
http://en.wikipedia.org/wiki/Human_skullhttp://en.wikipedia.org/wiki/Temporal_bonehttp://en.wikipedia.org/wiki/Orbital_bonehttp://en.wikipedia.org/wiki/Orbital_bonehttp://en.wikipedia.org/wiki/Temporal_bonehttp://en.wikipedia.org/wiki/Human_skull


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Road traffic accidents Trauma Sports injuryAssault & civil violence Industrial accidents

Complications : Most common is meningitis (Infection) Loss of consciousness & Confusion CSF leakage from ear or nose Diffuse axonal injury Heterotopic Ossification Respiratory complications

Contractures

Paralysis Coma Death

Severity of Head InjuriesIs determined by

Glasgow Coma Test (GSC) Length of unconsciousness (time in a coma) Length of post-traumatic amnesia (PTA)


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Grades of Consciousness Coma: there is no response to any stimulus. Semi-coma: Patient responds to pain and vigorous shake. Deep

and superficial reflexes are present.

Stupor: Patient is irritable and unco-operative and nospontaneous activity. Confusion: Patient cant think clearly or understand

surroundings.

Glasgow Coma Scale (GCS) Severity of head injuries is most commonly classified by

Glasgow Coma Scale (GCS) score, which generates a numerical

summed score for eye, motor, and verbal abilities.

Traditionally, a score of 13-15 indicates mild injury, a score of 9-12 indicates moderate injury, and a score of 8 or less indicates

severe injury.

In the last few years, however, some studies have included thosepatients with scores of 13 in the moderate category, while only

those patients with scores of 14 or 15 have been included as

mild. Concussion and mild head injury are generally

synonymous.

Common Functional Disabilities Physical Changes:

1-Motor Skills and Balance

2-Hearing Loss

3-Vision Affection


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4-Spasticity or Tremors

5-Speech Disorders

6-Fatigue or Weakness

7-Seizures

8-Taste and Smell Affection

Changes in Cognition and Thinking1-Memory and Attention Impairment

2-Reduce Speed of Information Process

3-Decreased Awareness

4-Receptive and Expressive Aphasia

Inability to understand what is being said or what is read

5-Executive Skills (Problem solving, organizational skills, etc)

Changes in Personality and Behavior1-Depression

2-Substance Use and Abuse3-Social and Emotional Problems

TreatmentSurgical treatmentPhysiotherapy

Surgical treatment


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The role of operative surgery in these patients is limited tocorrecting bone deformity, stopping bleeding and relieving

intracranial tension.

Physiotherapy Inpatient Role (ICU) (Coma) Outpatient Role

Role of Physiotherapy during ComaPhysical Therapy Goals1-Maintain normal ventilation and oxygenation.

2-Maintain musculoskeletal system within functional limit.

3-Improve Circulatory system function

4-Maintain Neurological system within functional limit

Pulmonary System1-Intubated Patient :

Modified postural drainage positionsa) Turn patient to both sides and manually hyperventilate the patientusing the ambu bag.

b) Use pulmonary hygiene techniques to mobilize

Secretions such as vibration, percussion, rib springs and

Shaking.


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c) Endotracheal suctioning

d) Position for relaxation to decreased dyspnea (the head

of the bed elevated to 30 degrees and lying on well)

2- Extubated or Non-Intubated Patient:

Modified postural drainage positiona) Pulmonary hygiene techniques to mobilize secretionb) Use Neuro-physiological facilitation of respiration to facilitate deep

breathing, increase lung volume and increase thoracic expansion.

c) Use tracheal tickle technique to elicit a coughd) Side lying the prone positions are the best positions to improve

oxygenation and ventilation.

Circulatory System1.PROM2.Elastic crepe bandage3.Compression unit4.Limb Elevation. Musculoskeletal System

1. Passive ROM of upper and lower extremities including prolonged

stretching.


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2. Use of splints (by keeping most joints in the neutral or functional

position). Inhibitive casting or patients shoes can also be used.

3. Proper positioning for all joints of the body.

Neurological System1.Patient must be oriented to place, person and time by health care

team and family members.

2.Decrease limb spasticity keep hips flexed and abducted, or positionpatient in side lying.

*For decerebrate posture, use asymmetric tonic reflex on affected side to

decrease upper limb extended tone.

*For decorticate posture, use Symmetric neck reflex to decrease flexor tone in

the upper limbs and extensor tone in the lower limbs.

3.Using ice pack can also decrease limb spasticity.4. Activities in the upright and bed mobility can be used to improve

muscles tone and facilitate active movement which will provide vestibular and

tactile stimulation and improve lung function.

5. Patient should be in the upright position as soon as possible (by

gradually raising the head, using the tilt table or transferring patient to the

chair) to prevent osteoporosis, to improve lung function.

6. Work on head and trunk control and use weight bearing activities forthe upper limbs while patient is at the edge of the bed to promote equilibrium

reactions and to improve muscles tone. The therapist can move the patient

passively in this position to give him feeling of weight shifting.


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7. the patient is sitting at the edge of the bed, ensure that his feet are well

supported to provide stimulation and feedback and to encourage some weight

bearing through the lower limbs.

Role of Physiotherapy (Outpatient)Goals of Physiotherapy:

Reduce muscle spasms, pain and stiffness Improve functional abilities such as rolling, sitting, standing and

walking

Retrain normal patterns of movement Improve balance and coordination Improve muscle strength and range of movement Improve posture Improve positioning and alignment Improve independence and quality of life

1- Respiratory Ex

To Improve Ventilation of lung2-Position Management:

Risk of pressure areas, contracture, and respiratorycomplications should be considered when a patient is positioned.

The patient should be moved between supine and right or leftside lying, if possible.

Too many pillows in the bed can cause contractures. One pillowunder the head is usually sufficient for comfort as too many

pillows may lead to contracture of the neck flexors. Pillows

placed under the knees can cause contracture of the knee flexors,

preventing full extension when standing is begun.

3- Mobilization/Verticalisation Training


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Mobilisation means bringing the patient into an upright seatedposition at the edge of the bed or outside the bed or to a

standing position.

Early mobilisation within the first 24 hours after injury reducesmortality and long-term disability

4- Prevention of Contracture (Stretching Ex)

Prevention of contracture is best achieved by the application oflow load prolonged stretches.

If stretching is not maintaining muscle length or if contracture isalready present, serial casting may need to be considered.

5- Serial Casting Serial casts are usually applied from 3 to 7 days then removed

and range of motion re-measured

Side effects or complications that can be caused by serial castinginclude:

a.Pressure areasb.Circulation restrictionc.Nerve compression at superficial points

6- Spasticity Management

7- ADL Training/Self-Care

Training of self-care activities and activities of daily living (ADL) topatients with sensory, motor, or cognitive dysfunction.

8- Co-ordination Ex


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9- Bladder Control Training

10- Balance and Gait Training

By vestibular rehabilitation techniques to compensate for balance disorders

StairsStart walking up four stairs. Relax 10 seconds. Slowly turn around and walk

back to your starting position. Relax 10 seconds.

Log RollsLay down on back on bed. Extend legs and arms; put arms over your head.

Rotate body as quickly as possible to the right and keep rolling until you

Return to the original position. Relax 10 seconds, and then roll the opposite

direction.

Walkers1-Use a walker without wheels to prevent slippage

2-Place a walker in front of your body while sitting upright.

3-Hold the walker and rise slowly from seat.

4-Hold the walker for 20 secs without moving body.

Fall Backs1-Sit upright on the edge of bed with feet firmly planted on the floor

2-Quickly fall backward on back. Rotate head to the right

3-Stay in this position for one minute. Return to original upright position.

Relax 10 secs.


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Head Injuries 1

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