slide headsdd
DESCRIPTION
XTRANSCRIPT
OVERVIEW
Head injury was first estimated occur in about 1 million years ago
Evidenced skull damage on human predecessors now called Australopithecus africanus
Java > 300.000 years ago
Peking > 100.000 years ago
Neanderthal > 40.000 years ago
Damage is found that there are two adjacent fracture lines in the posterior region of the skull
QS. Al-Maidah : 27-30 Tells the story of the first murder Adam’s children (Habil and Qabil)
Qabil hit Habil with a rock to the head until Habil killed
BRAIN INJURY
As defined by the National Head Injury Foundation“a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.”
HEAD INJURY-EPIDEMIOLOGY
1.5 million Non-fatal TBI’s 370,000 Hospitalizations 80,000 cases of neurological sequela 52,000 Die from TBI’s 4 billion annually for cost of treatment Peak incidence:
Males age 15-24 years
INTRODUCTION TO HEAD INJURIES
TIME IS CRITICAL Intracranial Hemorrhage Progressing Edema
Increased ICP Cerebral Hypoxia Permanent Damage
Severity is difficult to recognize Subtle signs Improve differential diagnosis
Improves survivability
1ST MANAGEMENT
Primary survey
Secondary survey
Definitive therapy
HEAD TRAUMA
Open • Skull compromised
and brain exposed
Closed• Skull not compromised
and brain not exposed
10Head Trauma -
CRANIAL INJURY
Trauma must be extreme to fracture Linear Depressed Open Impaled Object
DIRECT BRAIN INJURY TYPES
Coup Injury at site of
impact Contrecoup
Injury on opposite side from impact
Pathology of the Brain Injury:
* Not all the brain damage occurs at the time of injury * Basically two main stages of brain damage after injury - PRIMARY DAMAGE - SECONDARY DAMAGE * Last decade : Head CT Scan and MRI played very important role in diagnostic evaluation of head injury patients * Even with improved CT Scan and MRI, the precise type of damage may not be identifiable during life * The principal mechanism are : - CONTACT - ACCELERATION / DECELERATION
PRIMARY DAMAGE
* occurs at the moment of injury
* including : - laceration of the scalp
- fracture of the skull
- contusions and lacerations
- diffuse axonal injury
- intracranial hemorrhage
- other type of brain damage
SECONDARY DAMAGE
* results from complicating processes that are initiated at the moment of injury
* may not present clinically for a period of time afterward
* including : - hypoxia / ischemia - swelling - infection - brain damage due to elevated intracranial pressure
BRAIN INJURY
Response to injury
• Swelling of brain Vasodilatation with increased blood volume Increased ICP
• Decreased blood flow to brain Perfusion decreases Cerebral ischemia (hypoxia)
16Head Trauma -
SIGNS & SYMPTOMS OF BRAIN INJURY
Altered Mental Status Altered orientation Alteration in personality Amnesia
Retrograde Antegrade
Cushing’s Reflex Increased BP Bradycardia Erratic respirations
- Vomiting Without nausea Projectile
- Body temperature changes- Changes in pupil reactivity- Decorticate posturing
Assessment of Impaired Consciousness
•Use practical scale – Glasgow Coma Scale•Three features are in dependently observed : Points * EYE OPENING Spontaneous 4 To speech 3 To pain 2 None 1 * BEST MOTOR RESPONSE Obeys commands 6 Localized to pain stimuli 5 Withdraws from pain stimuli 4 Decorticate flexion 3 Decerebrate extension 2 None 1 * VERBAL RESPONSE Oriented 5 Confused conversation 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
CLINICAL FEATURES
Clinical Features Radiological Exam Pathologic name
Mild Head Injury unconsc < 10’ brain CT normal Concussion GCS 13 – 15 no neuro deficit
Moderate Head Injury unconsc 10’-<6hrs brain CT abnormal Contusion GCS 9 – 12 pos neuro deficit
Severe Head Injury unconcs > 6 hrs brain CT abnormal Contusion GCS 3 – 9 pos neuro deficit
SIMPLE HEAD INJURY GCS 15 no neuro deficit no unconsc
DIRECT BRAIN INJURY CATEGORIES
Focal Occur at a specific location in brain Differentials
Cerebral Contusion Intracranial Hemorrhage
Epidural hematoma Subdural hematoma
Intracerebral Hemorrhage Diffuse
Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury
FOCAL BRAIN INJURY
Cerebral Contusion Blunt trauma to local brain tissue Capillary bleeding into brain tissue Common with blunt head trauma
Confusion Neurologic deficit
Personality changes Vision changes Speech changes
Results from Coup-contrecoup injury
BRAIN INJURIES
Cerebral contusion
• Bruising of brain tissue Swelling may be rapid and severe
• Level of consciousness Prolonged unconsciousness,
profound confusion or amnesia
• Associated symptoms Focal neurological signs May have personality changes
22Head Trauma -
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Epidural HematomaBleeding between dura
mater and skull Involves arteries
Middle meningeal artery most common
Rapid bleeding & reduction of oxygen to tissues
Herniates brain toward foramen magnum
INTRACRANIAL HEMORRHAGEAcute epidural hematoma • Arterial bleed
Temporal fracture commonOnset: minutes to hours
• Level of consciousnessInitial loss of consciousness“Lucid interval” follows
• Associated symptomsIpsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death
24Head Trauma -
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Subdural Hematoma Bleeding within meninges
Beneath dura mater & within subarachnoid space
Above pia mater Slow bleeding
Superior sagital sinus Signs progress over several days
Slow deterioration of mentation
INTRACRANIAL HEMORRHAGEAcute subdural hematoma• Venous bleed
Onset: hours to days
• Level of consciousnessFluctuations
• Associated symptomsHeadacheFocal neurologic signs
• High-riskAlcoholics, elderly, taking anticoagulants
26Head Trauma -
INTRACRANIAL HEMORRHAGEIntracerebral hemorrhage
• Arterial or venousSurgery is often not helpful
• Level of consciousnessAlterations common
• Associated symptomsVaries with region and degreePattern similar to strokeHeadache and vomiting
27Head Trauma -
FOCAL BRAIN INJURY
INTRACRANIAL HEMORRHAGE
Intracerebral HemorrhageRupture blood vessel within the brainPresentation similar to stroke symptomsSigns and symptoms worsen over time
Basal SkullUnprotectedSpaces weaken
structureRelatively
easier to fracture
CRANIAL INJURY
Basal Skull Fracture Signs Battle’s Signs
Retroauricular Ecchymosis Associated with fracture of
auditory canal and lower areas of skull
Raccoon Eyes Bilateral Periorbital
Ecchymosis Associated with orbital
fractures
BASILAR SKULL FRACTURE
Battle’s sign Raccoon eyes
31Head Trauma -
CRANIAL INJURY
Basilar Skull Fracture May tear dura
Permit CSF to drain through an external passageway May mediate rise of
ICP Evaluate for “Target”
or “Halo” sign
CRAINIAL INJURIES
Penetrating trauma
33Head Trauma -
Bullet fragments
EDH
SDH
SAH
ICH
THANK YOU