Head Trauma

Waqar SaeedGroup B

PhysiologyPhysiology• Continuous blood flow of oxygen and glucose.

• Normal cerebral blood flow (CBF) is about 55mL/min per 100g of brain tissue.

• Rate below 20mL/min can result into ischemia and infarction.

• CPP = MAP – ICP• MAP (90-110mmHg)• ICP (5-15mmHg)

Cerebral Perfusion Cerebral Perfusion PressurePressure

• Net pressure of blood delivery to the brain.

• In a normal adult, CPP is generally regulated between 75 and 105 mmHg (can be more or less).

• Cerebral autoregulation.

• Most common pathophysiologic pathway is elevated ICP.

Monro Kellie DoctrineMonro Kellie Doctrine• The brain is protected by a rigid case, within

which there is no “extra” space.

• Skull (holds three things) Brain Blood Cerebro-Spinal Fluid (CSF)• An increase in any one of these three

“compartments” displaces the other two.• Only small volume increases can be tolerated

before intracranial pressure (ICP) begins to rise.

EpidemiologyEpidemiology• 3-4% of ER attendances

• 1500 cases per 100,000 population per year in UK.

• Leading cause of death and disability from childhood to early middle age.

Mechanisms of InjuryMechanisms of Injury• Motor vehicle crashes

• Sports Injuries

• Falls

• Penetrating trauma

Categories of injuryCategories of injury• Coup injury

• Countrecoup injury

• Diffuse Axonal injury

• Focal injury

ClassificationClassification

Primary Evaluation Primary Evaluation and Managementand Management

• Resuscitation according to ATLS guidelines.

• History

• Pupil Responsiveness

• Glasgow Coma Scale

Glasgow Coma ScaleGlasgow Coma Scale

• A 29-year-old woman was an unbelted passenger in a motor vehicle accident. On arrival to the hospital, the paramedics inform you that she opens her eyes in response to verbal stimuli. She is incoherent and withdraws from painful stimuli. Which of the following is the patient’s calculated Glasgow Coma Scale (GCS)?

• a.15• b.3• c.9• d.5• e.12

Primary InjuryPrimary Injury• Induced by mechanical force and occurs at the

moment of injury• Causes: Impact, Mechanical disruption of cells,

Vascular permeability or disruption,

Head InjuriesHead Injuries• Subgaleal hematoma

Scalp lacerationsScalp lacerations

Skull base fracturesSkull base fractures

Intracranial Intracranial HaematomaHaematoma

Case ScenarioCase Scenario• A 15 year old boy was hit with a baseball on his

head and he became unconscious. After about ten minutes, he regained consciousness, but he soon became lethargic, and over the next two hours, he was stuporous. His pupils were unequal. He was shifted to the radiology department for an urgent CT scan, which is shown

Extradural hematomaExtradural hematoma• Neurosurgical emergency

• Young population

• Rupture of middle meningeal artery

• Lucid interval with headache

• Ipsilateral pupillary dilatation and reduced consciousness

ManagementManagement• Stabilize acute life-threatening conditions and initiate

supportive therapy. Airway control and blood pressure support are the most important issues.

• Establish IV access, administer oxygen, and monitor.

• Administer IV crystalloids to maintain adequate blood pressure.

• Intubation, sedation, and neuromuscular blockade per protocol. There is some suggestion of increased mortality with prehospital intubation in retrospective reviews of trauma patients with moderate-to-severe head injury compared with patients intubated in the ED. Bag-valve-mask ventilation with good technique may be of more benefit to brain injured patients than prehospital intubation.

Acute Subdural Acute Subdural HematomaHematoma

• High energy Injury mechanism

• Conscious level impaired at presentation

• CT scan

Chronic Subdural Chronic Subdural HematomaHematoma

• antiplatelet and anticoagulant medications

• Cerebral atrophy in elderly stretch the bridging veins.

• Rupture after only minor trauma

• Degradation of clot leads to osmotic expansion

• Mass effect

SymptomsSymptoms• Expanding intracranial mass

• Pressure symptoms i.e headache, drowsiness, neurological deficit, seizures.

• Electrolyte imbalance and infections may be contributory

ManagementManagement• Burrhole procedure under local LA

• If clinically stable, a delay of 7-10 days to allow platelet function to normalize after withdrawal of aspirin

• Anticoagulation should be reversed by administration of Vit K

Aneurysmal Aneurysmal Subarachnoid Subarachnoid HemorrhageHemorrhage

• Berry Aneurysms develop at the branch points.

• Incidence of 10-15 per 100,000 population per year.

• Risk Factors, Age, Female gender, Hypertension, Smoking, Cocaine abuse and Family history of two first degree relatives.

• Genetic disorders.

Clinical featuresClinical features• Neck pain or stiffness• Loss of consciousness• Onset of headache during exertion• Thunderclap headache• Limited neck flexion

InvestigationsInvestigations• CT Scan

Cerebral AngiographyCerebral Angiography

Prevention of Prevention of Secondary InjurySecondary Injury

• Seizures

• Nutrition