kry head injury overview

8/4/2019 Kry Head Injury Overview

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Head Injury Overview

Traumatic head injuries are a major cause of death, and disability but it might be best to refer to

the damage done as traumatic brain injury.

The purpose of the head, including the skull and face, is to protect the brain against injury. Inaddition to the bony protection, the brain is covered in tough fibrous layers called meninges and

bathed in fluid that may provide a little shock absorption.

When an injury occurs, loss of brain function can occur even without visible damage to the head.

Force applied to the head may cause the brain to be directly injured or shaken, bouncing againstthe inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding

the brain, bruise the brain tissue, or damage the nerve connections within the brain.

Caring for the victim with a head injury begins with making certain that the ABCs of

resuscitation are addressed (airway, breathing, circulation). Many individuals with head injuries

are multiple trauma victims and the care of their brain may take place at the same time otherinjuries are stabilized and treated.

Skull Fracture

The skull is made up of many bones that form a solid container for the brain. The face is the

front part of the head and also helps protect the brain from injury. Depending upon the locationof the fracture, there may or may not be a relationship between a fractured skull and underlying

brain injury. Of note, a fracture, break, and crack all mean the same thing, that the integrity of

the bone has been compromised. One term does not presume a more severe injury than the

others. Fractures of the skull are described based on their location, the appearance of the fracture,

and whether the bone has been pushed in.

Location is important because some skull bones are thinner and more fragile than others. Forexample, the temporal bone above the ear is relatively thin and can be more easily broken than

the occipital bone at the back of the skull. The middle meningeal artery is located in a groove

within the temporal bone. It is susceptible to damage and bleeding if the fracture crosses thatgroove.

Basilar skull fractures occur because of blunt trauma and describe a break in the bonesat the base of the skull. These are often associated with bleeding around the eyes (raccoon

eyes) or behind the ears (Battle's sign). The fracture line may extend into the sinuses of

the face and allow bacteria from the nose and mouth to come into contact with the brain,causing a potential infection.

In infants and young children, whose skull bones have not yet fused together, a skullfracture may cause a diastasis fracture, in which the bone junctions (called suture lines)

widen.


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Fractures can be linear (literally a line in the bone) or stellate (a starburst like pattern)and the pattern of the break is associated with the type of force applied to the skull.

Penetrating skull fractures describe injuries caused by an object entering the brain. Thisincludes gunshot and stab wounds, and impaled objects to the head.

A depressed skull fracture occurs when a piece of skull is pushed toward the inside ofthe skull (think of pressing in on a ping pong ball). Depending upon circumstances,

surgery may be required to elevate the depressed fragment.

It is important to know whether the fracture is open or closed (this describes the conditionof the skin overlying the broken bone). An open fracture occurs when the skin is torn or

lacerated over the fracture site. This increases the risk of infection, especially with adepressed skull fracture in which brain tissue is exposed. In a closed fracture, the skin is

not damaged and continues to protect the underlying fracture from contamination from

the outside world.

Intracranial Bleeding

Intracranial (intra=within + cranium=skull) describes any bleeding within the skull.Intracerebral bleeding describes bleeding within the brain itself. More specific

descriptions are used based upon where the blood is located.

Bleeding in the skull may or may not be associated with a skull fracture. An intact skull isno guarantee that there is not underlying bleeding, or hemorrhage, in the brain or its

surrounding spaces. For that reason, plainX-raysof the skull are not routinely performed.

Epidural, subdural, and subarachnoid bleeding are terms that describe bleeding in thespaces between the meninges, the fibrous layered coverings of the brain. Sometimes, theterms hemorrhage (bleeding) andhematoma(blood clot) are interchanged. Because the

skull is a solid box, any blood that accumulates within the skull can increase the pressurewithin it and compress the brain. Moreover, blood is irritating and can causeedemaor

swelling as excess fluid leaks from the surrounding blood vessels. This is no different

than the swelling that can occur surrounding abruise on an arm or leg. The onlydifference is that there is no room within the skull to accommodate that swelling.

Subdural Hematoma

When force is applied to the head, bridging veins that cross through the subdural space(sub=beneath +dura= one of the meninges that line the brain) can tear and bleed. Theresultant blood clot increases pressure on the brain tissue. Subdural hematomas can occur

at the site of trauma, or may occur on the opposite side of the injury (contracoup:

contra=opposite + coup=hit) when the brain accelerates toward the opposite side of theskull and crushes or bounces against the opposite side.

Chronic subdural hematoma may occur in patients who have had atrophy (shrinkage) oftheir brain tissue. These include the elderly and chronic alcoholics. The subdural space
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increases and the bridging veins get stretched as they cross a much wider distance. Minor

or unnoticed injuries can lead to some bleeding, but because there is enough space in theskull to accommodate the blood, there may be minimal initial symptoms. Asymptomatic

(producing no symptoms) chronic subdural hematomas may be left to resolve on their

own; however, it may require attention if the individual's mental status changes or further

bleeding occurs.

Depending upon the neurologic status of the affected individual, surgery may be required.Epidural Hematoma

Thee dura is one of the meninges or lining membranes that covers the brain. It attaches atthe suture lines where the bones come together. If the head trauma is epidural

(epi=outside +dura) the blood is trapped in a small area and cause a hematoma or bloodclot to form. Pressure can increase quickly within the epidural space, pushing the clot up

against the brain and causing significant damage.

While individuals who sustain small epidural hematomas may be observed, most requiresurgery. Patients have improved survival and brain function recovery if the operation to

remove the hematoma and relieve pressure on the brain occurs before they have lostconsciousness and become comatose.

An epidural hematoma may often occur with trauma to the temporal bone located on theside of the head above the ear. Aside from the fact that the temporal bone is thinner than

the other skull bones (frontal, parietal, occipital), it is also the location of the middle

meningeal artery that runs just beneath the bone. Fracture of the temporal bone isassociated with tearing of this artery and may lead to an epidural hematoma.

Subarachnoid Hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the innerarachnoid layer of the meninges. The injury is often associated with an intracerebral

bleed (see below). This is also the space where cerebral spinal fluid (CSF) flows and

affected individuals can develop severeheadache,nausea, vomiting, and a stiff neck

because the blood causes significant irritation to this meningeal layer. It is the sameresponse that can be seen in patients who have aleaking cerebral aneurysmormeningitis.

Treatment is often observation and controlling the symptoms.

Intraparenchymal Hemorrhage/Intracerebral Hemorrhage/Cerebral Contusion

These terms describe bleeding within the brain tissue itself and can be considered a bruiseto the brain tissue.

Aside from the direct damage to the brain tissue that was injured, swelling or edema isthe major complication of an intracerebral bleed.
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Surgery is not often considered except in situations in which the pressure within the skullincreases to the point at which part of the bone is temporarily removed to allow the brainto expand. When and if the brain swelling resolves, another operation replaces the piece

of skull that was removed.

Diffuse Axonal Injury or Shear Injury

A potentially devastating brain injury occurs when the brain injury occurs to the axons,the part of the neurons or brain cell that allows those cells to send messages to each other.

Because of the damage of electrical flow between cells, the affected individual often

appears comatose with no evidence of bleeding within the brain. The mechanism ofinjury is usually acceleration-deceleration, and the nerve endings that connect the brain

cells rip apart.

Treatment is supportive, meaning that there is no surgery or other treatment presentlyavailable. The patient's basic needs are met hoping that the brain will recover on its own.

Most don't.

Concussionsmay be potentially considered a milder form of this type of injury.\
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Picture of the areas of the brain subject to injury


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Picture of an epidural, subdural, and intracerebral hematomas

Head Injury Causes

Traumatic head injury affects more than 1.7million people in the United States each year

including almost a half million children; 52,000 people die.

Adults suffer head injuries most frequently due to falls, motor vehicle crashes, colliding or beingstruck by an object, and assaults. Falls and being struck are the most common causes of head

injury in children.

National traumatic brain injury estimates from the CDC


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Head Injury Symptoms

It is important to remember that a head injury can have different symptoms and signs, ranging

from a patient experiencing no initial symptoms tocoma.

A high index of suspicion that a head injury may exist is important, depending upon the

mechanism of injury and the initial symptoms displayed by the patient. Being unconscious, even

for a short period of time is not normal. Prolonged confusion,seizures, and multiple episodes ofvomiting should be signs that prompt medical attention is needed.

In some situations, concussion-type symptoms can be missed. Patients may experience difficultyconcentrating, increased mood swings, lethargy or aggression, andaltered sleep habitsamong

other symptoms. Medical evaluation is always wise even well after the injury has occured.

Head Injury in Infants and Young Children

Infants often visit health care practitioner because of a head injury. Toddlers tend to fall as theylearn to walk, and falls remain the number one cause of head injury in children. While guidelines

exist regarding the evaluation of head injury victims, they tend to be applied to those older than 2

years of age.

A minor head injury in an infant is described by the American Academy of Pediatrics as the

following: a history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or

child who is alert or awakens to voice or light touch.

Infants are usually unable to complain about headache or other symptoms. Therefore, basicguidelines as to when to seek medical care can include the following:

Altered mental status. The child is not acting or behaving normally for that child. Vomiting
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Scalp abnormalities including lacerations and swelling that may be associated with skullfracture Forehead contusions tend to be less worrisome than occipital (back of the head)contusions

SeizureOften a careful physical examination is all that is needed to assess the infant's risk forintracranial hemorrhage, but some testing may be considered.

CT scanmay be indicated based upon the health care practitioner's assessment of the child. Plainskull X-rays may be considered to look for a fracture, as a screening tool to decide about the

need for a CT scan.

Usually, if the health care practitioner finds no evidence for concern, the infant can be

discharged home for observation. While parents may choose to, there is no need to keep the

infant awake or waken them should they fall asleep.

Head Injury Guidelines and Assessment: Glasgow Coma Scale

The Glasgow Coma Scale was developed to provide a simple way for health care practitioners of

different skill levels and training to quickly assess a patient's mental status and depth of coma

based upon observations of eye opening, speech, and movement. Patients in the deepest level of

coma:

do not respond with any body movement to pain, do not have any speech, and do not open their eyes.

Those in lighter comas may offer some response, to the point they may even seem awake, yet

meet the criteria of coma because they do not respond to their environment.

Glasgow Coma Scale

Eye Opening

Spontaneous 4

To loud voice 3

To pain 2

None 1

Verbal Response

Oriented 5

Confused, Disoriented 4

Inappropriate words 3
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Incomprehensible words 2

None 1

Motor Response

Obeys commands 6Localizes pain 5

Withdraws from pain 4

Abnormal flexion posturing 3

Extensor posturing 2

None 1

Glasgow Coma Scale

A person who is awake has a Glasgow Coma Scale of 15, while a person who is dead would

have a score of 3. The abnormal motor responses of flexion and extension describe arm and legmovement when a painful stimulus is applied.

The term "decorticate" (de=not + cortex=conscious part of the brain) refers to the cortexof the brain, the part that deals with movement, sensation, and thinking.

"Decerebrate" (de=not + cerebrum= brain and brainstem) means that the cortex and thebrain stem that unconsciously controls basic bodily functions like breathing and heart

beat, may not functioning.

Trauma patients are often "touched" by many health care practitioners; from first responders,

EMTs, emergency physicians, surgeons and neurosurgeons. Not only is it important to assessthe depth of coma but also to know if the patient is improving or deteriorating. The GlasgowComa Scale allows that analysis to occur.

The scale is used as part of the initial evaluation of a patient, but does not assist in making the

diagnosis as to the cause of coma. Since it "scores" the level of coma, the GCS can be used as a

standard method for any health care practitioner to assess change in patient status.

When to Seek Medical Care

Call 911 or activate your local emergency response service should any person sustain asignificant head injury. This includes all persons with loss of consciousness who do notimmediately waken and return to normal as well as those who show signs of weakness or

numbness on one side of their body, complain of difficulty speaking, or have vision loss.These are the same symptoms as a person having astroke.

Mechanism of injury is also an important consideration. Persons in a motor vehiclecollision or who have fallen from a height should be kept still with their neck protected,

in case there is an associated spinal cord injury.
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Other symptoms that should prompt seeking medical care include confusion, loss ofshort-term memory, and repeatedvomiting.

A less specific symptom but one that can also be used with children is to decide whetherthe person is acting like his or herself. This is a subtle and non specific way of evaluating

an injured person, but if there is concern that they are not acting "normal", medical care

should be accessed.

Persons with head injuries who are impaired because of alcohol or drugs should bebrought for medical attention and evaluation.

Those who are taking prescription blood thinning medications such aswarfarin(Coumadin), dabigatran etexilate (Pradaxa),enoxaparin(Lovenox), andheparinshouldseek medical care for all head injuries, even if it is very minor.

Head Injury Diagnosis

The physical examination and the history of the exact details of the injury are the first steps in

caring for a patient with head injury. The patient's past medical history and medication usage

will also be important factors in deciding the next steps. Plain skull X-rays are rarely done for theevaluation of head injury. It is more important to assess brain function than to look at the bones

that surround the brain. Plain X-ray films may be considered in infants to look for a fracture,

depending upon the clinical situation.

Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for

bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look forbleeding in the sinuses of the face associated with basilar skull fractures. CT does not assess

brain function, and patients suffering axonal shear injury may be comatose with a normal CT

scan of the head.

Numerous guidelines exist to give direction as to when a CT should be completed in patients

who present awake after sustaining a minor head injury.

Head Injury Treatment

Head Injury Self-Care at Home

Many people who hit their heads do not need to seek medical attention. People often hit their

heads on a cupboard or trip and fall on a soft surface, get up and dust themselves off and are

otherwise well.

Occasionally, a bump can occur underneath the skin of the scalp or forehead. This 'goose egg' is

a hematoma on the outside of the skull and is not necessarily related to any potential bleedingthat can affect the brain. Treatment is the same as any other bruise or contusion and includes ice,

and over-the-counter pain medication.
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Head Injury Medical Treatment

Treatment for head injury will be individualized for each patient depending upon the underlying

injury and the patient's situation.

As with any other injury, the ABCs of resuscitation take priority to restore or support breathingand circulation in the body. Care for the head injury often occurs at the same time other injuries

are attended to in the multiply traumatized patient.

Head Injury Prevention

Falls are the number one cause of head injuries. Some, like toddlers falling when learningto walk, are unavoidable. Others may be preventable, especially in the elderly.

Opportunities exist to minimize the risk of falling at home with the use of proper floor

coverings, the use of assist devices such as canes and walkers, and by evaluating homes

for high risk areas like bathrooms and stairs. A primary care health care practitioner or a

county health nurse may be able to help with home assessment.

Routine use of helmets may decrease head injury while riding a bicycle or motorcycle.Their use is also encouraged for sporting activities like skateboarding, skiing, and

snowboarding.

Head injuries are a major consequence of motor vehicle crashes. Lives can be saved bywearing seatbelts, driving cars with air bags, and by avoiding risky driving behavior(drinking and driving, texting while driving).

Head Injury Prognosis: Outlook and Recovery

The recovery from head injury depends upon the amount of damage inflicted upon the brain. Not

surprisingly, the brain cannot recover from severe injury, but the goal of treatment is to return as

much function as possible.

Of note is thatconcussion, once thought to be relatively minor, may have more long-term effectsthan initially appreciated and should not be ignored.

Synonyms and Keywords

head trauma, concussion, subdural hematoma, diffuse axonal injury, epidural hematoma, closed

head injury, cerebral contusion, intracranial hemorrhage, head bleed, intraparenchymalhemorrhage, DIA, depressed skull fracture, nondepressed skull fracture, linear skull fracture,

penetrating head trauma, basilar skull fracture, head injury, headache,worst headache of yourlife, brain dead, brain death, fatal head injury, subarachnoid head injury, subdural hematoma,

epidural hematoma, blood clot in the brain, burst blood vessel in the brain
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Concussion Diagnosis

The doctor will make sure that there are no severe or life-threatening injuries first and then will

further evaluate the severity of the head injury.

History of the injury: If you can, give the doctor the following details about the injury:

How long the person may have been unconscious. Details about how the injury happened, such as the speed of travel in a car accident, the height

of a fall, or the size of the person or object that hit the victim.

Past medical history: Tell the doctor about the history of any of the following:

Currentmedications, especiallywarfarin(Coumadin) or platelet inhibitors clopidogrel (Plavix)and aspirin and dipyridamole (Aggrenox)

Allergies to medications Prior head injury or concussion, neurologic injury, or surgeries Bleeding disorder or history of easy bleeding or bruising

During the physical examination, the doctor will:

Assess normal neurologic function such as reflexes and mental status. Examine the patient for other associated injuries, such as a neck injury orwhiplash, that are

common with head injury.

Inspect for bleeding from the ears or nose as well as bruising around the eyes or behind the earsthat is commonly seen with certain types of fractures to the base of the skull.

Many times people are concerned about a cut (laceration) on the scalp or face, and the doctormay not seem to take much notice. These cuts may bleed and appear serious, but severe or life-

threatening bleeding from such a cut is rare and would be recognized right away. The doctor's

main concern will be to assure that there is not serious brain damage, or a neck or torso injury.

The cut can be repaired later.

Looking inside: The best way to evaluate a person's head injury is with aCT scan. This machinetakes cross-sectionalX-raysof the head (or other body parts), and a computer reassembles the

information into images to let the doctor see details of the inside of the body. When a CT scan is

used for a head injury, the doctor will look for evidence of bleeding under the skull or within the

brain tissue itself.

With less serious head trauma, the doctor may choose not to do a CT scan. A minor concussioncan safely be observed either at home or in the hospital for 24-48 hours. If no other serious

signs of injury develop, the person will usually be safe.

Skull X-rays are no longer routinely used to evaluate a person with a concussion. A concussion may be accompanied by a skull fracture. The patient may still have a skull fracture

even though the doctor does not perform a CT scan or take X-rays. This is acceptable. The
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presence of a fracture does not, alone, increase the likelihood of an injury to the brain unless

there are also other signs of head injury.

o Skull fractures almost always heal well.Castsare not used on the head.o In rare cases, a leptomeningealcystmay form. These are bulges of the bone and tissue

at the site of the fracture, which develop months later. There is no way to predict their

occurrence or to prevent them.

o If the patient notices a bump forming months after a head injury, see a doctor. X-rays ofthe skull may be done at that time, and if there is a leptomeningeal cyst forming, the

patient will be referred to a neurosurgeon for evaluation and treatment.

In the past, concussions were commonly graded on a scale according to severity. Most

commonly, concussions are referred to as symptomatic or asymptomatic (meaning thatsymptoms are or are not present, respectively). Neurologists may do further testing to grade a

concussion's severity.

Concussion Treatment

Concussion Self-Care at Home

Bleeding under the scalp, but outside the skull, creates a "goose egg" or large bruise (hematoma)at the site of the head injury. A hematoma is common and will go away on its own with time.

The use of ice immediately after the trauma may help decrease its size.

Do not apply ice directly to the skin - use a washcloth as a barrier and wrap the ice in it.You may also use a bag of frozen vegetables wrapped in cloth, as this conforms nicely to

the shape of the head.

Apply ice for 20-30 minutes at a time and repeat about every two to four hours. There islittle benefit after 48 hours.

Rest is important to allow the brain to heal.In 2010, the American Academy of Neurology called for any athlete suspected of having a

concussion to be removed from play until the athlete is evaluated by a physician. If a concussionis suspected due to a sports injury, the Centers for Disease Control recommends implementing a

4-step plan:

1. Remove the athlete from play.2. Ensure that the athlete is evaluated by a health care professional experienced in

evaluating for concussion. Do not try to judge the severity of the injury yourself.

3.

Inform the athlete's parents or guardians about the possible concussion and give them thefact sheet on concussion.

4. Keep the athlete out of play the day of the injury and until a health care professional,experienced in evaluating for concussion, says they are symptom-free and it's OK toreturn to play.

A repeat concussion that occurs before the brain recovers from the first - usually within a shortperiod of time (hours, days, or weeks) - can slow recovery or increase the likelihood of having
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long-term problems. In rare cases, repeat concussions can result inedema(brain swelling),

permanent brain damage, and even death.

Concussion Medical Treatment

Bed rest, fluids, and a mild pain reliever such asacetaminophen(Tylenol) may be prescribed.

Ice may be applied tobumpsto relieve pain and decrease swelling. Cuts are numbed with medication such as lidocaine, by injection or topical application.

The cut is then cleansed thoroughly with a saline solution and possibly an iodine solution.

The doctor will explore the injury to look for foreign matter and hidden injuries. Thewound usually is closed with skin staples, stitches (sutures), or, occasionally, a skin glue

called cyanoacrylate (Dermabond).

Hematoma Overview

A hematoma is a collection of blood, usually clotted, outside of a blood vessel that may occurbecause of an injury to the wall of a blood vessel allowing blood to leak out into tissues where itdoes not belong. (heme=blood + oma=tumor or collection). The damaged blood vessel may be

an artery, vein, or capillary; and the bleeding may be very tiny, with just a dot of blood or it can

be large and cause significant blood loss. It is a type ofinternal bleedingthat is either clotted or

is forming clots. Hemorrhage is the term used to describe active bleeding and is often graded ona severity score of one to four (15% to >40% of total blood volume). Hematoma describes

bleeding that has already started to become clotted. However, the distinction sometimes is not

clear as some hematomas enlarge over time as active bleeding can add to the mass of thehematoma.

Hematomas are often described based upon their location in the body, whether it is in the skull(intracranial: intra=within +cranium=skull), under the fingernail (subungual: sub=underneath +

ungual=nail), or in the earlobe.

Hematomas of the skin may also be named based upon their size. Petechiae are tiny dots of blood

usually less than 3mm (0.12 inch) while purpura is less than 10mm (0.40 inch) and ecchymosis is

greater than 10 mm. Ecchymosis is commonly considered a bruise.

Hematomas form when a blood vessel leaks into surrounding tissue. The injury to a blood vessel

wall may occur spontaneously or may be due to trauma. While the word trauma is often thoughtto be a major injury, it can also refer to minor damage that can occur routinely. The violence of a

sneeze orcoughmay cause blood vessels in the face to break and cause small amounts ofbleeding. The body is usually able to repair the damaged vessel wall by activating the blood

clotting cascade and forming fibrin patches. Sometimes the repair fails if the damage is extensiveand the large defect allows for continued bleeding. If the bleeding occurs in a tiny capillary

blood vessel, only a drop or two of blood may be lost into the surrounding tissue causing

petechiae to form. If there is great pressure within the blood vessel, for example a major artery,the blood may continue to leak and cause an expanding hematoma that cause significant blood

loss andshock.
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Blood that escapes from the blood stream is very irritating and may cause all the symptoms of

inflammation including pain, swelling and redness. Symptoms of a hematoma depend upon theirlocation, their size and whether they cause associated swelling,edemaor pressure on adjacent

structures such as blood vessels and nerves.

Hematoma Causes

Hematomas are usually caused by trauma, whether it is the result of a car accident, a minorbump, a cough, or an unknown event. The blood within blood vessels is continually flowing and

therefore does not clot or coagulate. When blood leaves the circulatory system and becomes

stagnant, there is almost immediate clotting unless the individual is taking anticoagulation

medication to preventblood clots(these may includeaspirin,warfarin[Coumadin],clopidogrel[Plavix) anddipyridamole[Persantine]). The greater the amount of bleeding that occurs, the

larger the hematoma.

Blood vessels that are fragile may contribute to hematoma formation. For example, ananeurysm

or weakening in a blood vessel wall may gradually cause blood vessel cell walls to come apartfrom constant exposure to the blood flowing and spontaneously leak.

There are many people who take blood thinners or anti-coagulation medications. Examples

include warfarin (Coumadin), aspirin, clopidogrel andprasugrel(Effient). These medicationsincrease the potential for spontaneous bleeding and for allowing hematomas to expand because

the body cannot efficiently repair blood vessels and blood continues to leak through the damaged

areas.

Occasionally, diseases (for example, autoimmune diseases and bacterial infections) may occur

that decrease the number of platelets in the blood stream or their ability to function. The platelets

are the cells that help initiate blood clot and fibrin formation. If platelets are inhibited, bleedingcan continue and hematomas can develop and expand. Examples of bacterial infections and

autoimmune diseases include:

finger infection, ankylosing spondylitis, and onychomycosis.

All these situations may exist independently to cause a hematoma or two or more may occurtogether.
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Hematoma Symptoms

Hematomas cause irritation and inflammation. Symptoms depend upon their location andwhether the size of the hematoma or the associated swelling and inflammation causes nearby

structures to be affected. The common symptoms of inflammation include redness, pain, and

swelling.

Hematomas tend to resolve over time.

The initial firm texture of the blood clot gradually becomes more spongy and soft as theclot is broken down by the body.

The shape changes as the fluid drains away and the hematoma flattens.


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The color changes from that of a purplish-blue bruise to yellows and browns as the bloodchemicals gradually are removed and the hematoma resolves.

Depending upon its location, the discolorations may travel through different tissue planes by

gravity. For example, a forehead hematoma may cause bruising beneath the eyes and seem to

travel to the neck as it resolves over time. However, there are specific situations that may occurwith hematomas in various parts of the body that show symptoms that are unique to the location

of the hematomas. They are listed below.

Specific Hematoma Symptoms

Hematomas may occur commonly and have little importance while others are life-threatening.

Many times it is a matter of location and situation that makes the hematoma a critical condition

instead of an inconvenience.

Hematoma in Menstruating or Pregnant Women

For example, in women, duringmenstruationsmall blood clots may be passed from the vagina as

the uterus empties itself as part of the normal menstrual cycle.

Bleeding in pregnancyis never normal except for a short time after the baby is born. In the first

trimester, vaginal bleeding may indicate that there is athreatened miscarriageand should prompt

the expectant mother to seek medical care. Not all bleeding leads to amiscarriageand manypregnancies may continue to full term with a normal baby.

Bleeding near term may an indication of a major obstetrical emergency and medical care shouldbe accessed immediately. The two worrisome conditions in third trimester bleeding include

placenta previaand placental abruption. Placenta previa describes the situation where theplacenta covers the uterus and blocks the baby's path from leaving the uterus. As the cervix

dilates, blood vessels within the placenta are stretched and torn and cause painless vaginalbleeding. Abruption describes a situation where the placenta prematurely separates from the

uterus wall and decreases the ability to transfer oxygen rich blood to the fetus. Placental

abruption usually causes significant pain.

Hematomas of the Head

Intracranial hematomas describe blood clots that occur within the skull. These clots affect brain

function because any bleeding or swelling may cause increased pressure to build within the

closed space of the bony skull. The increased pressure squeezes the brain and causes it to stopfunctioning appropriately. Symptoms may includenausea, vomiting,headache, and mental

alterations. Intracranial hematomas are named based upon where they are located, either within

the brain, the tissues that line the brain, or in the spaces that bathe the brain in fluid(CSF=cerebrospinal fluid).

Epidural hematomas occur in the epidural space, outside the dura lining of the brain.These hematomas often occur due to trauma and associated tearing of arteries that line
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the inside of the skull supplying the brain with blood. Because of the way the dura is

attached to the skull, small amounts of blood can cause significant increases in pressureandbrain injury.

Subdural hematomas occur because of trauma and damage to the veins that line thebrain. This causes a slower leak of blood into the subdural space. The space below the

dura has much more room in it and more blood can be tolerated before brain function

suffers. As people age, they lose some brain tissue and the subdural space is relativelylarger. The bleeding into the subdural space may be very slow, gradually stop and not

cause acute symptoms. These chronic subdural hematomas are often found incidentally

on computerized tomography (CT) scans as part of an evaluation for confusion orbecause another traumatic incident occurred.

Intracerebral (intra= within + cerebrum=brain) hematomas are blood clots that arelocated within the brain tissue itself. They may be due to bleeding from uncontrolled high

blood pressure, an aneurysm leak or rupture, trauma, tumor orstroke.

Subarachnoid hemorrhage is another type of intracerebral bleeding where blood leaksfrom an aneurysm into the subarachnoid space causing symptoms like intense headache,

neck stiffness, and vomiting. Blood within this space may clot or form a hematomapreventing the normal circulation and drainage of cerebrospinal fluid or CSF (the fluid

that bathes and provides nutrition to the brain).Hydrocephalusdescribes this condition.

Some intracerebral hematomas will also leak into the subarachnoid space

Scalp hematomas occur on the outside of the skull between the bone and the skin of thescalp. There are numerous layers to the scalp and the hematoma may be located in any ofthose layers. While a scalp hematoma cannot press on the brain and cause symptoms, it is

a signal that a head injury has occurred and there may also be underlying brain injury.

This is especially true for neonates and infants.
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Subungual Hematomas

Some hematomas cause significant pain because they are trapped in small spaces that do not

allow room for the bleeding to expand. For example, asubungual hematomaunderneath the

fingernail may be intensely painful because there is no room between the nail bed and the tightly

adherent nail bed. A few drops of blood that can accumulate from a crush injury like hitting a

finger with a hammer may cause exquisite pain. The treatment may include burning a small holethrough the nail itself to allow the blood to drain.


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Other Hematomas

Other hematomas cause problems because they press on the underlying tissue and that pressure

may hamper the normal blood supply and cause long lasting damage and scarring.

Hematomas of the ear may occur if an injury causes bleeding to the outside helix orcartilage structure of the ear. Blood can get trapped between the thin layer of skin and the

cartilage itself and since the ear cartilage gets its blood supply directly from the overlyingskin, a hematoma can decrease blood flow causing parts of the cartilage to shrivel and

die. This is a common complication seen in wrestlers and boxers.

Nose injuries may cause a similar issue with the cartilage that makes up the septum of thenose. A septal hematoma may form associated with abroken noseand if not recognized

and removed, the cartilage can break down and cause a perforation of the septum.

Internal bleeding into the abdomen may be life-threatening depending upon the causeand the situation. Hemorrhage and hematoma may be due to a variety of injuries orillnesses but regardless of how the blood gets into the abdomen, the clinical finding is

that of peritonitis, irritation of the lining of the abdomen.

Hematomas may occur in solid organs like the liver, spleen and kidney or they mayoccur within the walls of the small intestine or colon. Hematomas may also form withinthe lining of the abdomen called the peritoneum or behind the peritoneum in the

retroperitoneal space (retro=behind) where the kidneys are located.


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Hematomas and bleeding due to orthopedic injuries are common because of how bloodrich bones are. Bone marrow is where much of the body's blood production occurs and afracture may cause significant blood loss.Compartment syndromeis an uncommon

complication of bleeding and hematoma due to injury. The muscles of the forearm and

shin are contained in compartments that tightly adhere to bone. If a hematoma due to

fracture or contusion grows and expands, the pressure within the compartment canincrease to the point where blood cannot flow to muscle causing it to die. This is a true

orthopedic emergency and requires an operation to filet open the compartments to allow

room for the swelling and decrease the pressure. Symptoms of compartment syndromeinclude intense pain made worse with movement of the fingers or toes, numbness and

tingling of the extremity, and decreased pulses in the hand or foot.

When to Seek Medical Care

Most hematomas are due to minor trauma and the patient is aware of the injury and its

circumstances. Most resolve without any consequence and need no evaluation.

It is important to pay attention to specific hematomas because of their complications. Head

injuries should always be taken seriously because a small amount of blood and clot can causesignificant pressure changes within the skull and perhaps lead to brain damage.

Blood clots are not normal in the urine or inbowel movementsbecause they may be associated

with significant bleeding. Blood in these locations may be associated with infections, cancers,

tumors, or other lesions that can be life-threatening but potentially curable if found early. (Pleasenote thatbladder infectionsmay be associated with hematuria orblood in the urineand may not

need further evaluation once the infection has been treated; clot and hematoma formation is

rare.)

While most people havebruisingas a common injury due to the minor accidents of daily life,

some people with bleeding disorders where their blood lacks certain clotting factors may develop

unexplained bruising and bleeding and may benefit from seeking medical care. Similarly,patients who take blood thinners are at higher risk of bleeding from minor injuries and it is

prudent for these people to seek medical attention if they sustain even minor injuries.

A relatively uncommon infection,meningitis in adultsorchildren, can be caused by the bacteria,

Neisseria meningitidis (meningococcus). Symptoms may include headache with high fever,

confusion, vomiting, and stiff neck associated with a petechial rash (small hematomas visible in

the skin). This infection is seen in high school and college age students and is potentially quickly

lethal. If this disease is suspected, medical care should be sought immediately.

Hematoma Diagnosis

Most hematomas can be evaluated and safely treated without laboratory or radiology tests. Often

the care provider will be able to take a history and perform a physical examination and decidethat no further evaluation is required.
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However, depending upon the injury or presentation, blood tests may be ordered, including a

hemogram to assess the red blood cell count (often the hemoglobin and hematocrit are measured)and clotting studies, including an INR (international normalized ratio), and PTT (partial

thromboplastin time, a blood test that measures how long it takes for blood to clot). The INR is

routinely measured in individuals taking the blood thinning medication warfarin, to help monitor

the individual's medication dosing.

Depending upon the site of injury or other associated factors, the care provider may request othertesting be done.CT scansare useful in looking for blood in the brain or abdomen. Ultrasound is

often used for pregnant patients who present with vaginal bleeding.

Hematoma Treatment

Hematoma Self-Care at Home

Most hematomas of the skin are due to contusions and can be treated with rest, ice, compression,

and elevation (RICE). They will gradually resolve over time. Depending upon the location,immobilization of the area for a few days may speed healing, but there needs to be a balance

between healing and retaining range of motion of the affected body part.

Over-the-counter (OTC)pain medicationsincludingacetaminophenandibuprofenmay be useful

in controlling the inflammation and pain. It is important to remember that even OTC medicationshave side effects and their use should be discussed with a health care practitioner or pharmacist.

For example, patients taking blood thinners should be cautious taking ibuprofen because of the

risk of stomach bleeding while patients who have liver disease should carefully monitor theamount of acetaminophen they take.

Hematoma Medical Treatment

Medical care and definitive treatment of a hematoma depends upon its location, what body parts

are being affected, and what symptoms are present. For example, a small hematoma of the brain

may be observed if the patient is fully awake, while another patient with a head injury in a comamay require an operation. The same may be true with a patient with an intra-abdominal

hematoma. If the patient is stable, observation may be appropriate but if are in shock, some

surgical intervention may be required.

Hematoma Follow-Up

Most hematomas resolve spontaneously and need no further evaluation.

Since blood is a rich medium full of nutrients, some hematomas may become infected.

Individuals with a hematoma should monitor for signs of increased pain, warmth, and redness.This may be difficult to differentiate from the symptoms of inflammation of the hematoma itself.

However, infections often are associated withfeverand there may be pus and red streaking that

develops around the hematomas that give clues that an infection is brewing.
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Patients taking blood thinners may be at risk for continued bleeding and the amount of bleeding

may need to be monitored by repeated blood tests measuring the hemoglobin and INR.

Hematoma Prevention

Accidents happen and most hematomas are inevitable.

For persons taking anti-coagulation medications, it is wise to avoid participating in events withhigh risk of injury. For patients taking warfarin (Coumadin), it is important to monitor the

medication dosing on a regular basis to keep the blood thinned and the INR in the appropriate

range for the disease being treated.

Hematoma Prognosis

Blood vessels are routinely injured and may leak blood causing hematomas or bloodclots.

Depending upon their size and location, hematomas may be insignificant or may causelife-threatening damage.

People who take blood thinners like warfarin (Coumadin) and clopidogrel (Plavix) are athigher risk of bleeding from minor injuries.

Most hematomas resolve by themselves and need no further treatment, but some mayrequire surgical treatment.

Injuries to the head should be taken seriously because of the risk of bleeding causinginjuries like epidural, subdural and intracerebral hemorrhage

Subarachnoid Hemorrhage

Subarachnoid hemorrhage is the result of a blood vessel bursting in the subarachnoid space,which is the area just outside of the brain. This causes the area to quickly fill with blood.

Symptoms of Subarachnoid Hemorrhage

As a result of the rapid, intense pressure, the most common symptom of subarachnoid

hemorrhage is sudden, severe headache. This pain is often described afterward as the worst

headache ever experienced by the patient. Other symptoms include neck pain, nausea, andvomiting. In some cases, loss of consciousness and death occur.

Causes of Subarachnoid Hemorrhage

The most frequent cause of subarachnoid hemorrhage is abnormalities in the arteries located atthe base of the brain. Called cerebral an,eurysms, there are small areas of either rounded orirregular swellings in the arteries. As the swelling continues the arteries weaken, and become


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prone to breaking. While subarachnoid hemorrhages can occur in people of any age and any

gender, they are slightly more common in women than in men.

Prognosis of Subarachnoid Hemorrhage

Prognosis is grim, with mortality and permanent disability a common result of subarachnoidhemorrhage. About 35 percent of patients die from the first subarachnoid hemorrhage, while

another 15 percent die from a subsequentaneurysmwithin days or weeks. Some degree of

permanent brain damage is common among survivors.

Diffuse Axonal Injury

Diffuse axonal injury occurs in about half of all severe head traumas, making it one of the mostcommon traumatic brain injuries. It can also occur in moderate and mild brain injury. A diffuse

axonal injury falls under the category of a diffuse brain injury. This means that instead of

occurring in a specific area, like a focal brain injury, it occurs over a more widespread area. In

addition to being one of the most common types of brain injuries, its also one of the mostdevastating. As a matter of fact, severe diffuse axonal injury is one of the leading causes of death

in people with traumatic brain injury.

Causes of Diffuse Axonal Injury

Diffuse axonal injury isnt the result of a blow to the head. Instead, it results from the brainmoving back and forth in the skull as a result of acceleration or deceleration. Automobile

accidents, sports-related accidents, violence, falls, and child abuse such as Shaken Baby

Syndrome are common causes of diffuse axonal injury.

When acceleration or deceleration causes the brain to move within the skull, axons, the parts of

the nerve cells that allow neurons to send messages between them, are disrupted. As tissue slidesover tissue, a shearing injury occurs. This causes the lesions that are responsible for

unconsciousness, as well as the vegetative state that occurs after a severe head injury.

A diffuse axonal injury also causes brain cells to die, which cause swelling in the brain. This

increased pressure in the brain can cause decreased blood flow to the brain, as well as additional

injury. The shearing can also release chemicals which can contribute to additional brain injury.

Symptoms of Diffuse Axonal Injury

The main symptom of diffuse axonal injury is lack of consciousness, which can last up to sixhours or more. A person with a mild or moderate diffuse axonal injury who is conscious may

also show other signs of brain damage, depending upon which area of the brain is most affected.
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Diagnosing Diffuse Axonal Injury

If the patient has sustained a mild diffuse axonal injury and is conscious, he or she will be askeda variety of questions including how the injury occurred and what symptoms the patient is

experiencing, in addition to questions designed to test the cognitive ability of the patient.

Tests will then be run to determine the severity of the injury. Since most patients with severe

diffuse axonal injury are unconscious following the injury, the only way to determine the extent

of the injury is to run these tests. These tests may include:

Magnetic Resonance Imaging (MRI)This test uses magnets, radio waves, and a computerscreen to show detailed cross-sections of the brain. This is the preferred test for diagnosing

diffuse axonal injury.

CT ScanThis test uses an x-ray machine and a computer monitor to show detailed images ofthe interior of the brain. CT scans may results in false negatives, so cant be relied on to give

definitive results when it comes to diffuse axonal injury.

Evoked PotentialsCommonly called the SSEP, BAER, and VEP, these tests look at the visual,auditory, and sensory pathways in the brain.

Electroencephalogram (EEG)This test measures the electrical activity in the brain.Treatment of Diffuse Axonal Injury

Immediate measures will be taken to reduce swelling inside the brain, which can cause additionaldamage. In most cases, a course of steroids or other medications designed to reduce

inflammation and swelling will be administered, and the patient will be monitored. Surgery is not

an option for those who have sustained a diffuse axonal injury.

If the patient has sustained a mild or moderate diffuse axonal injury, the rehabilitation phase willfollow once the patient is stabilized and awake. During this phase of treatment, the patient andhis or her family will work with a multidisciplinary staff including doctors, nurses, physical and

occupational therapists, and other specialists to devise an individualized program designed to

return the patient to the maximum level of function. The rehabilitation phase may include:

Speech therapy Physical therapy Occupational therapy Recreational therapy Adaptive equipment training

Counseling

Prognosis of Diffuse Axonal Injury

It is thought that diffuse axonal injury can occur in just about every level of severity, withconcussion thought to be one of the milder forms. In mild to moderate forms of diffuse axonal

injury, recovery is possible, with the mildest forms of diffuse axonal injury often resulting in few


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if any long-term issues. About 90 percent of survivors with severe diffuse axonal injury remain

unconscious. The 10 percent that regain consciousness are often severely impaired.

Hematoma

The brain is protected by fluid that prevents it from being injured during everyday activities andmovements. In situations where the fluid isnt able to adequately absorb force - such as those that

result from a hard blow or a quick stop - the brain is knocked against the interior of the skull and

becomes bruised. This causes something called an intercranial hematoma which is abraininjury. There are three types of intercranial hematomas:subdural hematoma,epidural

hematoma, and intraparenchymal hematoma.

Causes of Hematoma

The most common cause of intercranial hematoma is injury to the head. This can occur from a

motorcycle accident, car accident, or other traumatic accident in which the brain experiences

force as a result of a blow to the head or a quick stop. Mild head trauma can also causehematoma, but mostly among older adults.

Signs and Symptoms of Hematoma

Signs and symptoms can occur immediately after a head trauma, or can take as long as days or

weeks to show up. The symptoms show up as the pressure on the brain increases. Common signsand symptoms include:

Headache Nausea Dizziness Vomiting Weakness in limbs on one side of the body Dilated pupils Confusion Slurred speech

Prognosis for Hematoma

Hematoma often requires surgery. Victims of hematoma may experience attention issues,emotional issues, amnesia, and headache for some time following treatment. Recovery depends

upon many factors, including the severity of the hematoma a well as when it was discovered and

treated, and can sometimes be incomplete. Most adults can expect to see the majority of theirrecovery within six months, while children recover faster and more completely than adults.

SKULL FRACTURES
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If the skull is struck by a blunt object, the impact area will flatten with stress

oscillating outwards laterally --like a rock hitting a pool of water. If sufficient pressure

is applied the skull will fracture. Usually the break occurs at the site of impact.

Skull fractures are of three types, depressed, linear or basilar. Basilar fracture are

relatively uncommon whereas approximately 75% are linear, the remainder beingdepressed. In general, head injuries are also considered as either closed, or open if

accompanied by scalp laceration and/or if the fracture extends into the sinuses or

middle ear (Adams & Victor 1993 ).

BASILAR FRACTURES

Basilar fractures often extend into the base of the skull and are difficult to detect

unless quite severe. However, existence of a basal skull fracture may be indicated by

cranial nerve damage or hormonal-endocrine abnormaltiies (such as from damage to

the pituitary). Fractures near the sella tursica (at the base of the skull) may tear thestalk of the pituitary such that in consequence diabetes, impotence, and reduced libido

may result.

In some instances these fractures may extend in an anterior, posterior or lateral

direction. If they extend in an antero-lateral direction, tearing of the olfactory, optic,

oculomotor, trochlear, first and second branches of the trigeminal, and the facial and

auditory nerves may occur, thus disrupting olfaction, vision, eye movements, and/or

cause unilateral facial paralysis and hearing loss. If extending laterally they may

damage the mastoid bone and tympanic membrain of the inner ear resulting in

dizziness and disturbances involving equilibrium. and a loss of hearing.

Basilar fractures are sometimes associated with tearing of the dura as well as CSF

leakage. Hence, a variety of related complications may occur including infection.

DEPRESSED FRACTURES

Usually with depressed factures, part of the skull will shatter into several fragments

which are driven downward toward the brain. If the dura is torn the brain is often

lacerated as well. Moreover, if the dura has been torn the patient becomes vulnerbale

to infection, particularly in that pieces of hair or other debri may be driven into thecranial vault. This in turn will later give rise to a host of symptoms including the

possible development of meningitis (Jennett & Teasdale, 1981).

Frequently, but not always, the meningeal artery may be torn and intracerebral,

extracerebral or an epidural hematomas may develop. Laceration and contusions are

usually found beneath the broken bone fragments, and subdural hematomas may


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develop on the contralateral side (Bakay et al., 1980). If not accompanied by a

laceration of the scalp, depressed fractures are described as closed.

In some cases, particularly if bone fragments have been driven into the brain and/or

with the development of hematomas, patients develop focal neurological signs

depending on which part of the brain has been compromised.

Approximatley 50% of those who suffer a depressed skull fracture do not lose

consciousness (Bakay et al., 1980; Jennett & Teasdale, 1981) and in many instances

the dura is spared and there is no gross evidence of neurological compromise. This

does not mean, however, that the brain has not been injured.

LINEAR FRACTURES

When the head is struck there usually results an inward deformation of the skull

immediately beneath the site of impact whereas the surrounding area is bent outward.In some instances the skull shatters (i.e. depressed fracture) whereas in the majority of

cases it will crack. Linear fractures are of two types, longitudinal and transverse.

Like depressed factures, patients may or may not lose consciousness. However, it has

been reported that patients with linear fractures who retain consciousness are 400

times more likely to develop a mass lesion (e.g. hematoma) as compared to comatose

patients who are 20 times more likely to develop intracranial hemorrhage (Jennett &

Teasdale, 1981).

The most common sites of linear fractures involve the temporal and parietal bones.Indeed, the temporal portion of the skull may fracture following trauma to any portion

of the cranium.

HEARING LOSS, VERTIGO, DIZZINESS, & BLINDNESS

Linear fractures involving the temporal-parietal bones may damage the auditory

meatus, eustachian tube, and ear drum causing hearing loss, tinnitus, disorders of

equilbrium and vertigo.

Facial Paralysis.

In some instances, longitudinal fractures may damage the cochlear nucleus and cause

injuries to the 7th and 5th cranial nerves which pass through this area before

innervating the skin and muscles of the face. When these nerves are crushed or

damaged there results a unilateral facial paralysis and loss of sensation. Transverse

fractures can also cause stretching of the 7th and 8th nerves and may damage the


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vestibular and cochlear portions of the labyrinth. Hence, facial paralysis and hearing

related abnormalities may also occur.

Anosmia.

Anosmia (loss of the sense of smell) and an apparent loss of taste (loss of aromaticflavor perception) are frequent sequala of head injury, especially following injuries to

the face and fractures involving the back of the head or frontal bone. Anosmia is due

to damage to the olfactory nerve, usually in the vicinity of the cribiform plate.

The cribiform plate is a wafer thin sheet of perforated bone through which the

olfactory nerves pass on their journey from the nasal mucosa to the olfactory bulbs.

Because this thin sheet of bone is perforated it is predisposed to fracture during head

trauma regardless of where the patient was struck. This may cause the olfactory

nerves to shear off thus resulting in a permanent loss of smell--anosmia. Patients are

unable to even detect markedly unpleasant odors. If odors can be detected, theolfactory nerve is intact.

If the shearing is unilateral the loss of smell will not be recognized by the patient. It is

only with complete bilateral shearing that patients begin to complain, usually noting

that they have suffered a loss of taste.

With damage to the olfactory nerve and cribiform plate, sometimes there also may

result a laceration or rupture of the meninges, If there is meningeal rupture

cerebrospinal fluid will leak into the nose. Frequently the only symptom is what

appears to be a continually "running nose". In some instances cerebrospinal fluid hasgushed into the patients nose when he has coughed or sneezed --well after the injury.

Hence, if a patient has a runny nose, loss of smell, but no cold or allergy, and has had

a head injury, a cerebrospinal fluid fistula secondary to meningeal rupture and

cribifrom plate fracture should be considered. If this is suspected he should be referred

immediately to a neurosurgeon. Sometimes a secondary consequence of rupture which

goes untreated is bacterial infection which may develop into menigitis.

Blindness.

Fractures near the sphenoid bone (which jutts out beneath and below the frontal bonewithin the skull) may result in laceration of the optic nerve. When this occurs the

patient becomes immediately and permanently blind. The pupil becomes permanently

dilated and is unreactive to light, although consensual reflexes are maintained. In

some cases, however, an indidual may be struck so hard that their eyes pop out of

their sockets. In others, although the eyes do not pop out, their main be strain on the

optic nerves thus causing visual problems and light sensitivity.


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kry head injury overview

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