SURGERY 2

HEAD INJURY

DR. SAFDAR H MALIK MD FCPS

MECHANISM OF HI

1-BLUNT INJURY

most common

*MOTOR VECHECLE ACCIDENTS

FALL

ASSAULTS

2-PENETRATING INJURY

GUN SHOTS INJURY

STABBING

EXPLOSIONS

9/1/2020

GCS

EYE	SPONTANEOUS EYE OPENING OPENING TO VERBAL COMMOND ON PAIN FULL STIMULI NO EYE OPENING	4 3 2 1
VERBAL	ORIENTED & TALKING CONFUSED &DISORIENTED INCOMPREHSIBLE SPEECH/ WORDS SOUNDS NO VERBAL RESPONSE	5 4 3 2 1
MOTOR	OBEYS COMMAND LOCALIZE PAIN WITHDRAWL PAIN FLEXTION TO PAIN(DECORTICATE POSTURING) EXTENTION TO PAIN (DECEREBRATE POSTURING) NO MOTOR RESPONSE	6 5 4 3 2 1

9/1/2020

TYPES OF HI ON BASIS OF GCS

MILD HI – GCS FROM 13-15
MODERATE HEAD INJURY-GCS 9-13
SEVERE HEAD INJURY-GCS 8 OR LESS

need intubation

3 is lowest no zero

9/1/2020

Extent of injury

SCALP INJURY
SKULL INJURY
BRAIN INJURY

9/1/2020

Scalp Injury

Contusions
Lacerations
Avulsions
Significant Hemorrhage

in children, hypovolemia and shock ( ttt: .stop bleeding . do CT . close wound

9/1/2020

SKULL INJURY / FRACTURES

9/1/2020

TYPES OF FRACTURES

9/1/2020

SKULL BASE FRACTURES SIGNS/SYPMTOMS

1-ANTERIOR SKULL BASE

RACCOUN EYES-BILATERAL PERIORBITAL ECCYMOSIS

CSF RINORRHEA

2-MIDDLE SKULL BASE

BATTELS SIGN -RETO AURICULAR ECCYMOSIS

CSF OTORIA

CRANIAL NERVES INJURIES

Cribriform plate → Loss of smell

9/1/2020 4. Temporal bone → CN 7,8

BRAIN INJURY CLASSIFICATION

ON MORFALOGY

PRIMARY

Primary injury caused by forces of trauma.

could progress to

SECONDARY

Secondary injury caused by factors resulting from the

primary injury

brain edema, herniation

hyponatremia ↓ 132

FOCAL INJURY

DIFFUSE INJURY

9/1/2020

SYSTEMIC INSULTS

HYPOXIA (PaO2 less than 60mmhg)
HYPOTENTION(systolic BP dropped < 90mmhg)
HYPO/HYPER CAPNIA (Pco2 <32 0r >35)
BLOOD LOSS ANEMIA

9/1/2020

Cont.

Seizures
Electrolytes imbalance
Coagulopathy
Infection
Hyponatremia
Iatrogenic (under resuscitation)
INTRACRANIAL INSULTS
Intracranial hypertension
Intracranial lesion
Cerebral edema

9/1/2020

Epidural Hematomas

very dangerous

Associated with skull fracture
Classic: Middle meningeal artery tear
Lenticular / biconvex
Lucid interval
Can be rapidly fatal
Early evacuation essential.
Outcome: 5% mortality.
Head Injury w/ LOC + Lucid Interval followed by deterioration

we have to do CT scan *

9/1/2020

Subdural Hematomas

Venous tear / brain laceration
Occur in 15% of severe head trauma.
Morbidity / mortality due to underlying brain injury
Rapid surgical evacuation recommended, especially if > 5 mm shift of midline.
Outcome: 35% mortality.
Increased risk in elderly and alcoholics due to decreased brain volume

9/1/2020

DIFFUSE AXONAL INJURY

Sudden acceleration-deceleration forces cause injury to the brain.

The injury is greatest in where the density difference is greatest. Most tearing occurs at the gray-white matter junction.

Neuronal disconnection secondary to severe brain injury.
Clinical: Low GCS without obvious lesion on CT Scan.
Location: Corpus callosum – Internal capsule- Midbrain (Tectum)-Descending corticospinal Tract.
Radiological: Punctate hemorrhage on MRI.
Outcome: Poor

9/1/2020

Subarachnoid Hemorrhage

Bleeding beneath the arachnoid membrane on the surface of the brain.
Most common cause of SAH is Traumatic.
SAH is a form of Stroke.
Symptoms:
- Severe Headache(Thunderclap)
- Confusion or decrease LOC/ COMA.
Diagnosis:CT Brain without contrast-LP-cerebral Angio.

9/1/2020

Intracerebral Hematoma “ICH”

Focal areas of hemorrhage within the parenchyma
Classified into Traumatic & Spontaneous.
Outcome: 40% mortality.
Symptoms depend on the site of bleeding.
Diagnosis: CTA- MRA-
Radiological: Spot sign.

9/1/2020

Direct Brain Injury Types

Coup

Injury at site of impact

Countercoup

Injury on opposite side from impact

9/1/2020

Large frontal

contusion with shift

9/1/2020

MANAGEMENT OF HI

INTIAL QUICK ASSESSMENT

ABCDF

FINAL ASSESSMENT
TYPE OF HI ON BASIS OF GCS
EXAMINATION OF HI
CT TRAUMA SURWAY

9/1/2020

FOCUS EXAMINATION

GCS
PUPILS EXAMINATION
LATERALIZING SIGNS
Hemiplegia, hemiparesis, Facial asymmetry.
Seizures focal or generalized
Memory
Visual disturbances

9/1/2020

Neurologic Exam interpretation

Pupillary Size + Reactivity

Fixed Dilated Pupil = Ipsilateral Intracranial Hematoma resulting in uncal herniation

Bilateral Fixed + Dilated = Poor Brain Perfusion, bilateral uncal herniation or severe hypoxia

Indicative of very poor neurological outcome

Neurological Posturing

Decorticate Posturing = Upper extremity flexion with lower extremity extension Cortical Injury above the midbrain

De cerebrate Posturing = Arm extension and internal rotation with wrist flexion Indicative of brainstem injury Very Poor predictor of outcome

9/1/2020

Moderate Head Injury

GCS Score = 9–13
Initial evaluation same as for mild injury
CT scan for all
Admit and observe
- Frequent neurologic exams
- Repeat CT scan

Admit and observe

Frequent neurologic exams & Repeat CT

Specialized Subset = “Talk and Die Syndrome”
Initially, talkative and without significant signs of external injury
Within 48 hours of injury, rapidly deteriorate
Epidural Hematoma is cause in 78-80% of cases
Patients with “talk and die syndrome” who present with a GCS > 9 but who deteriorate have been shown to have a worse outcome than patients who present with severe TBI at outset

9/1/2020

Severe Brain Injury

GCS Score = 3–8
Evaluate and resuscitate
Intubate for airway protection & admit in ICU
Focused neurologic exam
Frequent reevaluation
Identify associated injuries

9/1/2020

CONT.

ICP MONITOR
TREATMENT FOR BRAIN EDEMA
RAISED HEAD END OF PARIANT BED.
SEDATION
DVT CARE
ANTI CONVULSANT
MANITOL IV / Furosemide osmotic duration check Nat emb 3h
3% NORMAL SALINE
CONTROLED VENTILATION
DECOMPRESSIVE CRANIOTOMY

9/1/2020

Operative management.

ICP & OR EVD INSERTION
CRANIOTOMY FOR EVACUATION OF EDH
WIDE DECOMPRESSIVE CRANIOTOMY & EVACUATION OF ACUTE SUBDURAL HAEMATOMA /IC HAEMATOMA
WIDE DECOMPRESSIVE CRANIOTOMY FOR BRAIN EDEMA IN DIFFUSE BRAIN INSULT

9/1/2020

Operative

Craniotomy

Salvage operation used to manage increasing ICP
Removal of part of skull and underlying dura.
Decreases ICP, improves cerebral perfusion, prevents ischemia
Serves to limit secondary insults
Literature divided on true benefit

9/1/2020

EDH

9/1/2020

Intracranial Pressure (ICP)

10 mm Hg = Normal

20 mm Hg = Abnormal

40 mm Hg = Severe

Many pathologic processes affect outcome

Sustained ↑ ICP leads to ↓ brain function and outcome

9/1/2020

POST HI SEQUALE

POST TRAUMATIC SYNDROME
POST CONCUSSION SYNDROME
EPILEPSY
PERSISTENT VEGETATIVE STATE

9/1/2020

SUMMARY –WHAT TO DO

KEEP HEAD END AT 30 DEGREE P
MAINTAIN MAP AT 90 mmHg
MAINTAIN PCO2 AT 35 mmHg
Use isotonic saline for euvolemia
Frequent neurological exams
Liberal use of CT scan brain.
Early Neurosurgical consult

9/1/2020

SUMMARY –WHAT SHOULD NOT DO

Allow patient to become hypotensive
Over aggressive hyperventilation
Use hypotonic IV fluids
Long acting paralytics
Paralyze before complete examination
Depend upon clinical exam alone

9/1/2020

REFERENCES:

National Head Injury Foundation.
Atls manual of Head Trauma.
Tarascon Neurosurgery Pocketbook.

THANK YOU

9/1/2020

SURGERY 1

Head injury severity

Severity	GCS
Mild	≥ 13
Moderate	9- ≤ 12
Severe	≤ 8

Traumatic brain injury (TBI)-

is the leading cause of death in trauma patients- 50% of all traumatic deaths.

Primary injury the anatomic and physiologic disruption that occurs as a direct result of trauma

Secondary injury -extension (sequelae) of the primary injury, result from local swelling, increased ICP, hypoperfusion, hypoxemia, or other factors.

Aim: detection and treatment of primary injury and prevention of secondary injury

management

Maintain BP >90 mmHg, PaO2 >60 mmHg (75-100mmHg)
Assess GCS and lateralizing signs- pupil and motor function
- a neurological symptom that suggests an issue with one side of the brain or body
Pupillary asymmetry >1 mm suggests intracranial injury
Larger pupil is on the side of the mass lesion
Extremity weakness- detected by testing motor power
CT scan head- accurate localization of the lesion
Epidural or subdural hematoma: Treatment: evacuation
Intracerebral hematoma & contusion
Diffuse axonal injury: maintain brain perfusion & prevent rise in ICP.

(Image: Epidural Hematoma & Subdural Hematoma)

🩺 MedAtlax

Explorer

backup

SURGERY 2

HEAD INJURY

MECHANISM OF HI

GCS

TYPES OF HI ON BASIS OF GCS

Extent of injury

Scalp Injury

SKULL INJURY / FRACTURES

TYPES OF FRACTURES

SKULL BASE FRACTURES SIGNS/SYPMTOMS

1-ANTERIOR SKULL BASE

2-MIDDLE SKULL BASE

CRANIAL NERVES INJURIES

BRAIN INJURY CLASSIFICATION

PRIMARY

SECONDARY

FOCAL INJURY

SYSTEMIC INSULTS

Cont.

Epidural Hematomas

Subdural Hematomas

DIFFUSE AXONAL INJURY

Subarachnoid Hemorrhage

Intracerebral Hematoma “ICH”

Direct Brain Injury Types

Coup

Countercoup

Large frontal

MANAGEMENT OF HI

FOCUS EXAMINATION

Neurologic Exam interpretation

Pupillary Size + Reactivity

Neurological Posturing

Moderate Head Injury

Admit and observe

Frequent neurologic exams & Repeat CT

Severe Brain Injury

CONT.

Operative management.

Operative

Craniotomy

EDH

Intracranial Pressure (ICP)

POST HI SEQUALE

SUMMARY –WHAT TO DO

SUMMARY –WHAT SHOULD NOT DO

REFERENCES:

SURGERY 1

Head injury severity

Traumatic brain injury (TBI)-

management

Graph View

Table of Contents