Dr.

Karim Bhurgri
M.S General Surgery

Senior Registrar
Surgical Unit-III
LUM&HS-Jamshoro
Principles of management of head injuries & its complications
 Introduction
Head injury
 Accounts for 3-4% of emergency department
 Remains the leading cause of death & disability from early middle
age
 Road traffic accidents are the leading cause of head injury,
responsible for up to 50% of cases
 Other causes
o Fall
o Assault
o Firearms
 INTRACRANIAL PRESSURE
& Cerebral Blood Flow

 Normal cerebral blood flow (CBF) is about 55ml/min for every 100 g of brain
tissue
 Ischaemia results cerebral blood flow drops below 20 ml /min
 Flow depends on cerebral perfusion pressure, which is the difference between
the mean arterial pressure (MAP) & the intracranial pressure (ICP)

 CPP (75-105 mmHg) = MAP (90-110 mmHg)-ICP(5-15 mmHg)

• Auto-regulation can be impaired in the context of trauma, so that MAP & ICP
must be actively regulated in these patients to maintain proper perfusion
 The Monro-Kellie doctrine & herniation syndrome
Alexander Monro observe in 1783
o Any expansion in the contents, especially haematoma & brain swelling, may be initially
accompanied by
 Exclusion of fluid components, venous blood & cerebrospinal fluid (CSF)
 Further expansion is associated with an exponential rise in ICP
o Uncontrolled increase in ICP result in cerebral herniation.
o Typically,
 Herniation of uncus of the temporal lobe over the tentorium results in pupil abnormalities on the side of
any expanding haematoma.
 Cerebellar tonsillar herniation through foramen magnum compresses medullary vasomotor & respiratory
centers, classically producing Cushing’s traid:
 Hypertension
 Bradycardia
 Irregular respiration
 Patient is said coning & brain stem death will result without immediate intervention.
 CLASSIFICATION OF HEAD INJURY

Head injury Severity

Minor head injury GCS 15 with no loss of consciousness

Mild head injury GCS 14 or 15 with loss of consciousness

Moderate head injury GCS 9-13

Severe head injury GCS 3-8

Glasgow Coma Scale for Head Injury
Eyes open Spontaneously 4
To verbal command 3
To painful stimulus 2
Do not open 1

Verbal Normal 5
Confused 4
Inappropriate/words only 3
Sounds only 2
No sounds 1
Motor Obeys commands 6
Localises to pain 5
Withdrawal/flexion 4
Abnormal flexion 3
Extension 2
No motor response 1
 MINOR & MILD HEAD INJURY

 After exclusion of associated cervical spine injury,

consider the possibility of a ‘lucid interval’ that may
precede delayed deterioration due to expanding
intracranial haematoma.
• In general, patients with isolated head injuries &
without ongoing deficits can be safely discharged from
the emergency department, provided they meet suitable
criteria,
Discharge criteria in minor & mild head injury
o GCS 15/15 with no focal deficit
o Normal CT scan if indicated
o Patient not under the influence of alcohol or drugs
o Patient accompanied by a responsible adult
o Verbal & written head injury advice: seek the medical attention if:
 Persistent/worsening headache despite analgesia
 Persistent vomiting
 Drowsiness
 Visual disturbance
 Limb weakness or numbness
Guidelines for CT scan in head injury
o Indications for CT scan in head injury within 1 hour
 GCS <13 at any point
 GCS <15 at 2 hours
 Focal neurological deficit
 Suspected open, depressed or basal skull fracture
 More than one episode of vomiting
 Post-traumatic seizure
o Indications for CT scan within 8 hours
 Age >65 years
 Coagulopathy (e.g. aspirin, warfarin, or rivaroxaban use)
 Dangerous mechanism of injury (e.g. fall from height, RTA)
 Retrograde amnesia > 30 minutes
 MODERATE & SEVERE TRAUMATIC BRAIN INJURY

•Resuscitation & evaluation

 Resuscitation according to ATLS Guidelines, beginning with
management of the airway cervical spine control & proceeding to
assess & manage breathing & circulation
History
 Obtained from witness & paramedics
o Exclude the associated multisystem & spinal injury in high energy mechanism
of injury
o Preinjury state (fits, alcohol, chest pian)
o Mechanism & energy involved in the injury (speed of vehicle, height fallen)
o Conscious state & hemodynamic stability of the patient after the accident
o Length of time taken for extrication
 Check the medication history, especially anticoagulants & antiplatelet
agents
 Primary Survey

 Ensure adequate oxygenation & circulation

 Exclude hypoglycemia
 Check the pupil size & GCS score as soon as possible
 Check for focal neurological deficit before intubation if possible
 Secondary Survey

 Battle’s sign, periorbital bruising & blood in the ears/nose/mouth may

point to a base of skull fracture
 Cervical spine fractures are common & must be actively excluded
 Log-roll to check the whole spine for steps & tenderness & for a per
rectum examination
 Surgical Pathology

Fractures: Skull Vault

 Conservative management for closed linear fractures of skull vault
 Open or contaminated fracture
o Debridement
o Prophylactic antibiotic therapy
Depressed skull fractures
o Inward displacement of a bone fragment by at least the thickness of skull
o Occurs, when small objects hit the skull at high velocity
o They are usually compound/open fractures
o Associated with
 Infection
 Neurological deficit
 Late-onset epilepsy
o Treatment
 Exploration & elevation, especially where intracranial air is present,
pointing to a breach in the dura mater
 Fractures that involve the air sinuses managed as open fracture
 Broad-spectrum antibiotics with or without exploration
Fractures: Skull base
o Clinical features
 Bleeding or CSF leak from
 Ears (otorrhoea)
 Nose (rhinorrhea)
 Bruising behind the ear or around the eyes
 Anosmia, facial palsy or hearing loss occurs when complicated by:
 Pituitary dysfunction
 Arterial dissection or
 Cranial nerve deficit
 CSF leak resolve spontaneously but persistent leak result in meningitis, so
repair is required
o Note: Blind nasogastric tube placement is contraindicated in these patients
Extradural Haematoma
o Results from rupture of an artery, vein or venous sinus in association with a
skull fracture.
o Classical injury is a fracture to the thin squamous temporal bone, with
associated damage to middle meningeal artery
o Transient loss of consciousness is typical & subsequent lucid interval with
head ache but without any neurological deficit
o As the haematoma expands, rapid deterioration & presents with cardinal
signs of brain compression & herniation
 Contralateral hemiparesis
 A reduced conscious level
 Ipsilateral pupillary dilatation
o Lentiform lesion on CT scan
o Require immediate transfer to a neurological unit for decision on evacuation
Acute subdural haematoma
o High-energy injuries, or elderly/anticoagulated
o Generally require urgent evacuation by craniotomy/craniectomy
Chronic subdural haemorrhage
o Common in elderly, especially in those on anticoagulant
o Clinical deficit result from osmotic expansion of a degrading clot over
days/weeks
o Diffuse hypodense lesion on CT scan
o Burr hole drainage is usually required
o Anticoagulant should be reversed by
 Vitamin K administration
 Clotting factor administration
Traumatic subarchnoid haemorrhage
oTrauma is commonest cause
oManaged conservatively
oThe possibility of spontaneous subarachnoid haemorrhage
actually leading to collapse & so causing a head injury
needs to be borne in mind & formal or CT angiography may
be required to exclude it.
Cerebral contusion
o Occurs where the brain is in contact with the irregularly rigid
inside of the skull, i.e. at the inferior frontal lobes & temporal
poles.
o Coup conter-coup refer to brain injury both at the site of impact &
distant to this, where the the brain impact on the side of skull as
the skull & brain accelerate & then decelerate out of synchrony
with each other
o CT scan reflecting their composition of injured brain matter
interspersed with acute blood loss.
o Rarely required surgical intervention
 Medical Management
 From
o Initial resuscitation
o Surgical intervention
o Subsequent phase of ICU management
 Medical management strategies aim is to minimize secondary head
injury through avoidance of
o Hypoxia
o Hypotension &
o Control of the Intra-Cranial Pressure (ICP)
 Unchecked, secondary injury leads to further cycle of deterioration
Medical management of head injury

 First line ICP control involves optimizing sedation, ventilation &

serum sodium levels
 Paralysis & external ventricular CSF drainage are important adjuncts
 There is little evidence for benefit with therapeutic hypothermia,
barbiturate coma or decompressive craniectomy
 Check pituitary function, consider seizure prophylaxis, commence
enteral nutrition within 72 hours
THANKS