CASUALTY UNIT Management of Head InjuryBy Dr. Akinniyi O.T

Clinical Services Dept- NOH Dala

OutlineIntroduction Epidemiology Clinical presentation Management Complications Prevention Conclusion

Introduction Definition: Injury to the cranial vault, content or covering in isolation or combination.Associated injuries: Facial, Cervical spineM:F==2:1, 80% of victims are 15-25yrs75% of fatalities following motorbike accidents.Causation: RTA, domestic violence/assault. industrial/occupational hazard.Major disability in patients with moderate/severe injuries.

Goal of treatment Control and treat 10 injury while preventing development of 20 injury.

Apparently trivial but potentially fatal injuries.

Apparently hopeless but potentially. salvageable injuries.

Hopeless injuries.

Clinical presentationHx: Altered or loss consciousness following trauma

Examination: vitals, GCS, head, ears, nostrils, eyes, pupillary size, light rxn, fundoscopy, face focal/lateralizing signs.

SpinePosturing: decorticate, decerebrate Chest, abdomen, pelvis, extremities

Investigations Skull: AP, Lateral, Townes

CT, MRI, Transfontanell scan(

Treatment: At the scene Quarantine and extraction to safetyAir way and cervical control

Breathing Control of haemorrhage

AVPU, semi-prone (Lt)Associated injuries

Transport Communication with receiving facility

Treatment: In Hospital CareResuscitation + primary surveySecondary survey

Indication and timing of surgical treatmentSurgical options

Management of complicationsSupportive care/care of the unconscious

Rehabilitation

Resuscitation + primary survey:Airway + cervical control: Breathing: supplemental intranasal O2, 300 head-up

Circulation: (Anyawu 2000,Richards 2001, P.Singh 2005) Choice of fluidAmount of fluidDuration of fluid therapyHypovolaemia at presentationHypertension at presentation

Disability: GCSExposure

Secondary surveyHx: medical conditions, lucid interval

Examination: GCS(30min-1hrly), pupils, lateralizing signs

Review of results: skull x-ray, brain ct, mri

Assessment

Mild +Moderate head injuryGrouping: i-iv based on GCSi: 9-12

ii: 13-14

iii: 15 with neurologic deficit/ skull fracture

iv: 15 no deficits of fracture

Severe Head injuryGCS 3-8

ICU

Supportive care

Supportive careHDU/ICU: Continuous Invasive monitoring Respiration/ Air wayPressure areasEyes Nutrition BladderBowelDVT prophylaxisSurveillance for nosocomial infection

Conditions complicating head injuryCerebral oedema: elevation, hyperventilation, mannitol.

Seizures.

Raised intracranial pressure: muscle relaxation, paralysis, controlled csf drainage, propofol.

Indication and timing of surgical RxtScalp: Laceration (6hrs).

Skull: Open/ significant depressed fracture.

Brain: intracranial collection, penetrating injury, persistent csf leakage, lateralizing signs.

Surgical optionsScalp: 10 closure, flaps, cortical drilling and 20 closure.

Skull: Elevation of depressed skull fractures, bone grafting, titanium plating, bone cement

Haematoma: Burr Hole(diagnostic/theraputic) drainageDura: 10 suturing, dural patch (water tight)

Brain injury: Debridement, lobotomy

Rehabilitation:Re-integration into the society

Head injury advice

ComplicationsEarly: seizures, amnesisa, abscess, encephalitis, meningitis, haematomas

Late: seizures, personality change, hemiplegias/hemiparesis, vegetative state, skull osteomyelitis

cosmetic

PrognosisSeverity of initial injury at presentation

Secondary brain injury

Adequacy of treatment

Age

Prevention:Primary: re-education, sit belts, helmets, pedestrian

Secondary: diagnosis, timely definitive intervention Tertiary: Re-engineering

Conclusion For those of us still writing exams coupled with the paucity of updated literature we should avoid disdain for that which is old while embracing the new.While controversies rage on we should give our patients the best within the context of current knowledge and evidence.

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