Head InjuryHead Injury

Dr.saad farhan al masoudiDr.saad farhan al masoudi

Is the most common cause of mortality and morbidity . Commonly affect healthy children and active young adults. Is a major public health problem. Is largely preventable.

*Causes : RTA 50%FFH Assault Sports Industrial accident

*prevention : Is the most effective means of improving survival rates.

Little can be done as a treatment, improving safety devices in cars.

safety laws : seat belts , helmets , …….est public education.

*

Classification of Head injuryClassification of Head injury1. skull fracture with or without brain injury 1. skull fracture with or without brain injury vault fracture vault fracture base fracturebase fracture2. Focal brain injury which includes 2. Focal brain injury which includes a.Brain contusion which define as abruises of neural parenchyma , a.Brain contusion which define as abruises of neural parenchyma ,

always traumatic , wedge in shape , involve cortex surface always traumatic , wedge in shape , involve cortex surface associate with intact pial associate with intact pial –– glial membrane and these contusion glial membrane and these contusion subdivided tosubdivided to

Coup ------ below site of impaction Coup ------ below site of impaction Contre coup ------ remote from site of impaed Contre coup ------ remote from site of impaed Intermediate ------ within brain parenchyma between site of impaction and Intermediate ------ within brain parenchyma between site of impaction and

opposite side of brain .opposite side of brain .bb. Hemorrhage / hematoma . Hemorrhage / hematoma epidural epidural subdural subdural Intra cerebral Intra cerebral petechial petechial

3.Diffuse brain injury 3.Diffuse brain injury a.concussion :- a transient reversible neurological a.concussion :- a transient reversible neurological

dysfunction due to trauma not sufficient to cause dysfunction due to trauma not sufficient to cause structural damage to bruin parenchyma .structural damage to bruin parenchyma .

b.diffuse axonal injury : structural damage to brain b.diffuse axonal injury : structural damage to brain leading to prolong coma not cansed by mass leading to prolong coma not cansed by mass effect , its severity depend on effect , its severity depend on

duration of acceleration duration of acceleration magnitude of injury magnitude of injury rate of acceleration rate of acceleration direction of accelerationdirection of acceleration . .

Mechanisms of Head traumaMechanisms of Head trauma

A. Contact injury : slow , focal brain injury this require that A. Contact injury : slow , focal brain injury this require that head strikes an object or is struck , regard less of whether head strikes an object or is struck , regard less of whether the blow causes the head to move after ward . and include .the blow causes the head to move after ward . and include .1. Local contact injury (effects ) examples ,1. Local contact injury (effects ) examples ,

linear skull fracture linear skull fracture depressed skull fracturedepressed skull fracture s.t. fracture base of skull s.t. fracture base of skull epidural hematoma epidural hematoma coup contusioncoup contusion

2. remote contact injury ( effects) :example2. remote contact injury ( effects) :example vault fraeture vault fraeture fracture base of skull fracture base of skull contre coup contusion contre coup contusion Intermediate coup contusionIntermediate coup contusion Intracerebral hemorrhageIntracerebral hemorrhage

B.Head motion ( inertial ) injury :B.Head motion ( inertial ) injury : inertial injury are often called head motion injury or inertial injury are often called head motion injury or

acceleration injuries because the result from violent head acceleration injuries because the result from violent head motion , regardless of whether the head moves because of motion , regardless of whether the head moves because of a direct blow or not .a direct blow or not .

Inertial loading of head cause rapid movement of the head Inertial loading of head cause rapid movement of the head that resultant injury is due only to the manner in which the that resultant injury is due only to the manner in which the head moves .head moves .

Head motion injuries termed acceleration injuries and these Head motion injuries termed acceleration injuries and these acceleration classified toacceleration classified to

transilation accelerationtransilation acceleration Rotational accelerationRotational acceleration Angular acceleration(both transition) and rotation typeAngular acceleration(both transition) and rotation type , ,

combine to gathercombine to gather ) )

Head motion injuries classified to :Head motion injuries classified to :1.skull 1.skull –– brain relative motion brain relative motion

• subdural hemtoma subdural hemtoma • contra coup contusion contra coup contusion • intermediate coup contusionintermediate coup contusion

2.Brain Deformation 2.Brain Deformation Concussion syndrome Concussion syndrome Diffuse axonal injuryDiffuse axonal injury Intracerebral hemorrhageIntracerebral hemorrhage Tissue tear hemorrhageTissue tear hemorrhage

pathophysiology of traumatic brain injurypathophysiology of traumatic brain injury 1. Ischemia which caused by 1. Ischemia which caused by

• ↑ ↑ ICP ICP • Local destructions by space occupying lesion .Local destructions by space occupying lesion .• Severe vasoconstriction caused by release of K+ from Severe vasoconstriction caused by release of K+ from

ICC to ECC . ICC to ECC . 2. Hypoxia due to 2. Hypoxia due to • Respiratory dysfunction Respiratory dysfunction • Inadequate ventilation Inadequate ventilation • Problems in O2 delivery Problems in O2 delivery 3. Acidosis : which a consequence of ischemia and hypoxic 3. Acidosis : which a consequence of ischemia and hypoxic

leading to lactic acid acidosis that affect protein leading to lactic acid acidosis that affect protein synthesis and function →cell membrane neuronal damage .synthesis and function →cell membrane neuronal damage .

4. free radicle formation : ( H2O2 ) which occur from 4. free radicle formation : ( H2O2 ) which occur from reperfusion after trauma → neural damage reperfusion after trauma → neural damage

5. ↑ neurotransmitter → release secondary to ischemia like 5. ↑ neurotransmitter → release secondary to ischemia like glutamate → neurotoxicity . glutamate → neurotoxicity .

Systemic manifestation of traumatic brain Systemic manifestation of traumatic brain injuryinjury

1. Abnormality of water and electrolyte homeostasis 1. Abnormality of water and electrolyte homeostasis *Hyper natremia *Hyper natremia

diabetes insipidns diabetes insipidns poor fluid intake . poor fluid intake .

*hypo natremia *hypo natremia SIADH with SIADH with ↑↑ blood volume blood volume Cerebral salt wasting syndrome same as SIADH but with decrease in blood volume Cerebral salt wasting syndrome same as SIADH but with decrease in blood volume

2. hormonal abnormalities ( hypo and hyper secretion of anterior pituitary 2. hormonal abnormalities ( hypo and hyper secretion of anterior pituitary hormones ) , increase catacholamine production .hormones ) , increase catacholamine production .

3. Metabolic change , ( hyper metabolic state , depressed cellular immunity 3. Metabolic change , ( hyper metabolic state , depressed cellular immunity 4. cardio pulmonary malfunction 4. cardio pulmonary malfunction cardiac subendocardial hemorrhage cardiac subendocardial hemorrhage

cardiac arrhythmia cardiac arrhythmia heart failureheart failure

pulmonary - neurogenic pulmonary edema ( few minute ) delayedpulmonary - neurogenic pulmonary edema ( few minute ) delayed pulmonary dysfunction 24 pulmonary dysfunction 24 –– 48 hr 48 hr

pathology of closed head injurypathology of closed head injury

1. soft tissue injuries of head and neck 1. soft tissue injuries of head and neck periorbital ecchymoses ( Raccoon eye ) periorbital ecchymoses ( Raccoon eye ) postauricular ecchymoses ( battle's sign ) postauricular ecchymoses ( battle's sign ) scalp ( abrasion , laceration , contusions ) scalp ( abrasion , laceration , contusions ) facial injury facial injury peripheral cranial nerve peripheral cranial nerve retinal hemorrhageretinal hemorrhage..

2. skull fracture :2. skull fracture : linear #: most common type seen in severe linear #: most common type seen in severe

head injury cause by out bending of bone at a head injury cause by out bending of bone at a distance from impact side as a result of general distance from impact side as a result of general deformation of skull . deformation of skull .

depressed # : can be define when the outer depressed # : can be define when the outer table of depressed segment of bone below the table of depressed segment of bone below the inner table of the non inner table of the non –– depressed segment . depressed segment .

comminuted # : multiple linear # .comminuted # : multiple linear # . diastatic # : are linear fractures along sutures diastatic # : are linear fractures along sutures

line resulting in separation of cranial sutures .line resulting in separation of cranial sutures .

3. Brain injuries :3. Brain injuries : A . primary brain injuries include.A . primary brain injuries include. 1. Focal injuries :1. Focal injuries : *Hematoma which are *Hematoma which are - intracerebral H.- intracerebral H. -extradural H.-extradural H. -subdural H.-subdural H. -subarachoid H.( most common )-subarachoid H.( most common ) *Contusion / lacerations of .*Contusion / lacerations of . - brain tissue - brain tissue - brain stem - brain stem - cranial nerve - cranial nerve - blood vessels - blood vessels - pituitary gland and - pituitary gland and -hypothalamus .-hypothalamus . 2. Diffuse injuries : 2. Diffuse injuries : -Concussion -Concussion -Diffuse axonal injuries-Diffuse axonal injuries . .

B. secondary brain injuries due to :B. secondary brain injuries due to : 1. Ischemia of brain tissue neural tissues caused by 1. Ischemia of brain tissue neural tissues caused by ↑↑Icp and herniation Icp and herniation Mass effect Mass effect K + extracellular release and vasoconstrictor K + extracellular release and vasoconstrictor 2. hypoxia dne to :2. hypoxia dne to : Hypotension Hypotension Hypoventilation Hypoventilation Respiration dysfunction Respiration dysfunction Inadequate O2 deliver to tissues .Inadequate O2 deliver to tissues .

Evaluation of patient with head traumaEvaluation of patient with head trauma

A . General evaluation : which include A . General evaluation : which include 1. head and neck , site of trauma 1. head and neck , site of trauma 2. other part of body like chest , abdomen , extremities .2. other part of body like chest , abdomen , extremities . 3. vital signs , BP , PR , RR 3. vital signs , BP , PR , RR 4. reason behind head trauma . 4. reason behind head trauma . B. neurological evaluation : which include B. neurological evaluation : which include 1. Glasgow coma scale ( GCS ) for state and level of consciousness.1. Glasgow coma scale ( GCS ) for state and level of consciousness. 2. pupils and cranial nerve examinations 2. pupils and cranial nerve examinations Pupillary light reflex , dolls eye( oculocephalic reflex ) , swallowing Pupillary light reflex , dolls eye( oculocephalic reflex ) , swallowing and vocal cord function . and vocal cord function . 3. motor responses : movement type , weakness , posture whether 3. motor responses : movement type , weakness , posture whether

flexor or extensor . flexor or extensor . 4. sensory responses : painful stimuli commonly include nail bed 4. sensory responses : painful stimuli commonly include nail bed

pressure or nipple pinching lead to patient arousal .pressure or nipple pinching lead to patient arousal .

5. Reflexes : 5. Reflexes : Brain stem reflexesBrain stem reflexes Cranial nerve reflexesCranial nerve reflexes Muscle stretch reflexesMuscle stretch reflexes 6. Respiration :6. Respiration : Cheyne Cheyne –– stokes breathing →cortical lesion stokes breathing →cortical lesion Uniform hyperventilation → pontine lesion Uniform hyperventilation → pontine lesion Irregular , ataxic breathing → medullar lesion Irregular , ataxic breathing → medullar lesion 7. Brain death examination : 7. Brain death examination : Apnea test Apnea test Brain stem reflexes Brain stem reflexes EEG ( electroencephalography ) EEG ( electroencephalography ) Angiography Angiography 8. Glasgow out come scale 8. Glasgow out come scale 5 → good recovery 5 → good recovery 4 → moderate disability , independent 4 → moderate disability , independent 3 → severe disability , conscious , dependent 3 → severe disability , conscious , dependent 2 → persistent vegetative state 2 → persistent vegetative state 1 → Death 1 → Death

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