BCM 229 Head Injury

HEAD INJURIES
Head injury occurs every 15 seconds and patients dies of head injury every 12 minutes.
Early transfer of appropriate patients and inco operation of neurosurgeons consultation is
essential. This will reduces morbidity and mortality
The Skull
• The skull is composed of the cranial vault (calvarium) and the base.
• The base of the skull is irregular and rough, allowing injury to occur as the brain
moves within the skull during acceleration and deceleration.
Skull Fracture
• Linear with no depressed skull fracture
• Depressed skull fractures
• Open skull fractures
• Basal skull fractures
The brain consists of the cerebrum, the cerebellum and brain stem.
1. The cerebrum is composed of right and left hemispheres
The left hemisphere, which usually contains the language centers, is often
referred to as the dominant hemisphere.
The frontal lobe is concerned with the emotions and motor function.
Occipital lobe with vision
The parietal lobe with sensory function
1
The temporal lobe regulates certain memory functions but can be a relatively
silent region on the right side.
2. The brain stem consists of
• The midbrain
• Pons and
• The medulla oblongata, which continues to form the spinal cord.
• The midbrain and the upper pons contain the retinacula activating system, which
is responsible for an awake state.
• Vital cardiopulmonary centers reside in the lower brain stem, the medulla, which
continues to form the spinal cord.
• The cerebellum controls movements, co-ordination and balance, surrounds the
pons and medulla in the posterior fossa.
Brain Injury
Alteration of consciousness is the hallmark of head injury
Increased intracranial pressure and decreased cerebral blood flow can depress the level of
consciousness.
Glasgow coma scale (GCS) provides a quantitative measure of the patient’s level of
consciousness. The GCS is the sum of scores for three areas of assessment
– Eye opening
– Verbal response
– Best motor response
Each graded separately
2
Eye Opening
• Spontaneous already open with blinking (normal) E =4 points
• To speech not necessarily to request for eye opening E=3 point
• To pain stimulus should not be applied to the face E=2 points
• None: E =1 point
Verbal Response
• Orientation- knows name, age etc. V=5 points
• Confused conversation- still answers questions V= 4 points
• Inappropriate words- speech is either exclamatory or random, but recognizable
words are produced V= 3 points
• Incomprehensible sounds- grunts and groans are produced but no actual words are
uttered. Do not confuse with partial respiratory obstruction V =2 points
• None V= 1 point
Best Motor Response
• Obeys commands M=6 points
• Localized pain M =5 points
• Withdraws- pulls away from painful stimulus M=4 points
• Abnormal flexion- decorticate posture M =3 points
• Extension response – decerebrate posture M =2 points
• No movement M- 1 point
Glasgow coma scale can be used to categorize patients.
3
• A patient in coma is defined as having GCS of 8 points are in coma.
• Those with more than 8 points are not in coma.
Diffuse Brain Injuries
1. Concussion:- a brain injury followed by a brief loss of neurological functions
2. Diffuse axonal injury: coma often lasting for days or weeks. It does not require
surgery
3. Contusion, Hematomas and Hemorrhage brain injuries may require emergency
surgery
Raised Intracranial Pressure
• The intracranial pressure is described as a relationship among volumes of CSF,
blood and brain
• Brain volume is relatively static except when cerebral edema occurs
• A small increase in intracranial mass volume causes very large increase in
intracranial pressure resulting in decrease of cerebral perfusion pressure.
EMERGENCY MANAGEMENT OF HEAD INJURY
Establish a specific diagnosis
– Need for surgery
– Diagnostic triage
Emergency management
4
Aim at Maintaining cerebral metabolic needs- supply oxygen plus glucose to the brain
Treat intracranial hypertension
Fluid management and to prevent edema
Diuretics= Manitol and furosemide
When seeking neurosurgical consultation you must relay the following patient
information:-
• Age of the patient
• Mechanism of injury
• Respiratory and cardiovascular status
• Results and neurological examination especially the level of consciousness,
pupillary reaction and presence of lateralized extremity weakness
• Presence and type of cerebral injuries
• The results of diagnostic studies if obtained

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HEAD INJURIES

Early transfer of appropriate patients and inco operation of neurosurgeons consultation is

essential. This will reduces morbidity and mortality

moves within the skull during acceleration and deceleration.

• Linear with no depressed skull fracture

• Depressed skull fractures

• Open skull fractures

• Basal skull fractures

1. The cerebrum is composed of right and left hemispheres

referred to as the dominant hemisphere.

Occipital lobe with vision

The parietal lobe with sensory function

silent region on the right side.

2. The brain stem consists of

• The mid- brain

• The medulla oblongata, which continues to form the spinal cord.

is responsible for an awake state.

continues to form the spinal cord.

• The cerebellum controls movements, co-ordination and balance, surrounds the

pons and medulla in the posterior fossa.

Alteration of consciousness is the hallmark of head injury

– Best motor response

Each graded separately

• Spontaneous already open with blinking (normal) E =4 points

• To speech not necessarily to request for eye opening E=3 point

• To pain stimulus should not be applied to the face E=2 points

• Orientation- knows name, age etc. V=5 points

• Confused conversation- still answers questions V= 4 points

• Inappropriate words- speech is either exclamatory or random, but recognizable

words are produced V= 3 points

uttered. Do not confuse with partial respiratory obstruction V =2 points

Best Motor Response

• Obeys commands M=6 points

• Localized pain M =5 points

• Withdraws- pulls away from painful stimulus M=4 points

• Abnormal flexion- decorticate posture M =3 points

• Extension response – decerebrate posture M =2 points

Glasgow coma scale can be used to categorize patients.

• Those with more than 8 points are not in coma.

Diffuse Brain Injuries

1. Concussion:- a brain injury followed by a brief loss of neurological functions

3. Contusion, Hematomas and Hemorrhage brain injuries may require emergency

Raised Intracranial Pressure

• The intracranial pressure is described as a relationship among volumes of CSF,

blood and brain

• Brain volume is relatively static except when cerebral edema occurs

• A small increase in intracranial mass volume causes very large increase in

intracranial pressure resulting in decrease of cerebral perfusion pressure.

EMERGENCY MANAGEMENT OF HEAD INJURY

Establish a specific diagnosis

– Need for surgery

Treat intracranial hypertension

Fluid management and to prevent edema

Diuretics= Manitol and furosemide

• Age of the patient

• Respiratory and cardiovascular status

• Results and neurological examination especially the level of consciousness,

pupillary reaction and presence of lateralized extremity weakness

• Presence and type of cerebral injuries