Lec 1 Head Injuries

Neurosurgery
Head and scalp injury

Medicose Prep Academy
Hina Wajid
MIT ,RMU (Batch 13)

HEAD INJURIES
Head injuries are classified according to the Structures involved as given below
Scalp
Skull
Brain
SCALP INJURY
if not controlled these

Scalp has rich blood
injuries can be
supply and lacerations
managed by
in scalp can give rise to
debridement and
severe bleeding
suturing of the wound.
SKULL INJURY
Injuries to skull are a result of crushing or other severe forces.
Fractures of skull may be linear or depressed .
A depressed fracture of the vault may cause extradural or subdural haematoma.
Fracture of the base of skull may cause CSF fistula, for example rhinorrhoea (CSF
leakage from nose), injury to olfactory facial and auditory nerves are most
vulnerable.
PHYSICAL SIGNS OF SKULL FRACTURE
Anterior
1.Basal fracture
Fossa
of anterior skull Fracture
cause blood
leakage in
periorbital 3.Nasal
tissue bleeding
(characteristic
raccoon or
panda bear
sign)
2.Cranial nerves 4.CSF

injury: 1 to 6 rhinorrhoea.
RACCOON EYE SIGN
Middle Fossa Fracture
Bleeding from ears
CSF otorrhea
Cranial nerves injury:

7 and 8 due to
petrous Bone fracture
Posterior Fossa Fracture
Bruise over the

Bruising over
Cranial nerves mastoid
sub-occipital
injury: 9-11 region(Battle
region
sign)
Battle sign
Management
Follow the guidelines provided by ATLS (A, B, C, D)
Nasogastric tube should never be attempted in emergency department in

case of base fracture of days of skull as it can aggravate bleeding.
Linear fractures are usually managed conservatively
Depressed bone fracture can be left as such if it is not deeply

depressed(less than skull bone thickness)
It should be elevated if depression is greater than skull bone thickness or

if It is associated with hematoma, fits or If there is open fracture
BRAIN INJURIES
Brain injury can be divided into primary and Secondary injuries.
Primary Brain Injury is the direct result of trauma
Which may occur at the site of impact (Coup injury) or as an extensive

contusion of brain opposite to the point of impact (Counter coup) injury.
It includes concussion, bone fragmentation, axonal injury and brain stem

contusion.
Types of primary brain injury
Diffuse Axonal injury:
It results from sheering of grey-white matter interface, causes microscopic

injury to the white matter resulting in brain atrophy concussion.
Cerebral concussion:
This is a clinical diagnosis and is defined by a period of amnesia
Cerebral contusion and laceration: These are visible as small areas of

hemorrhage on CT scan
Secondary Brain Injury
It occurs after the initial injury
It occurs due to Hypoxia, hypercapnea, and hypotention (Ischemia), intra

cranial hemorrhage (extradural, subdural hematoma), meningitis or epilepsy.
This is the main cause of hospital mortality after head injury.

Clinical Features of Brain Injury
Injury Most of the features
of brain injury are the
result of raised intracranial
pressure.
This rise in intra cranial

pressure reduces the
cerebral perfusion which is
shown by the formula.
Cerebral Perfusion =B. P –

ICP
Clinical Features of Brain Injury
This decrease in cerebral perfusion pressure can results in cerebral ischemia.
The resultant ischemia of cardio respiratory centre leads to reflex increase in

systemic blood pressure and bradycardia which is called Cushing reflex.
Patient may present with headache, projectile vomiting, hypertension and

papilloedema.
Patients with extradural haematoma may present with lucid interval (Patient
recovers from initial period of unconsciousness and then develops headache and
coma).
Management of Brain Injuries
Head injury is managed following the guidelines
Primary Survey and Resuscitation
This includes airway, breathing, circulation, disability and exposure.
Special care must be paid to immobilize the cervical spine before initiating any treatment
or manipulation as partial injury of cervical cord can be changed to complete injury by

excessive manipulation.
Minimal handling of patient should be with special care as spinal cord is threatened by
instability secondary to ligamentous injury.
Secondary Survey
It includes head to toe examination and thorough neurological assessment is

performed by GCS, which shows severity of head injury
Mild head injury (GCS: 3-8)
Moderate head injury (GCS: 9-13)
(Severe head injury=(GCS: 14 – 15)

Eye Response
4 Spontaneous
3 To voice
2 To Pain
1 =None
Verbal Response (V)
5 Normal Conversation
4 Disoriented conversation
3 Words, but not coherent
2 No words……only sounds
1 =None
Motor response
6 Normal
5 Localizes pain
4 Withdraws to pain
3-Abnormal flexion response or decorticate posture
extension response, Decerebrate
1=None
Definitive Treatment
It should be cause oriented and is described below

Reduction of Intra Cranial Pressure
Treatment of Intracranial Haemorrhage
Dealing with depressed fracture of skull
Control of fits
NURSING CARE OF UNCONSCIOUS PATIENT
Mannitol: 1g of 20% I/V bolus and 6hrly is effective in

controlling raised intra cranial pressure and it acts as
osmotic dehydrating agent, provided that blood brain
barrier is intact. Otherwise it can leak out into brain and
potentiates the mass effect.
Barbiturates: (Thiopentone sodium 3-5 Mg/kg)
Barbiturates can reduce ICP by some unknown mechanism
Steroids ,( Dexamethasone 4mg 6hrly) They decrease ICP
by stabilizing the blood Brain barrier
Hyperventilation: It is used to wash out

excessive carbon dioxide which can occur as a
result of bradycardia in raised intracranial
pressure.
Furosemide:It reduces the ICP by decreasing
cerebral edema and CSF by Production
Avoid free water as it intensify the cerebral
edema
Treatment of Intracranial Haemorrhage
Any extradural or subdural hematoma

should be evacuated immediately by
consulting with the neurosurgeon.
Dealing with depressed fracture of skull
The depressed bone can be left as

such if it is not deeply depressed.
(Less than skull bone thickness).
It should be elevated if depression is
greater than skull bone thickness and
is associated with haematoma or fits.
Control of fits
Patient with head injury can present with fits
Which can be controlled by
I/V lorazepam 1mg bolus.
Phenytoin.
Valproic acid
Airway
The single most important factor in unconscious
patients, regardless of the cause, is the maintenance of
airway.
Oropharyngeal airway tube should be inserted to
prevent the back fall the tongue and suction may be
required to remove excessive secretions from pharynx.
Tracheostomy should be considered in those for
remained unconscious for more than 5 days.
Feeding
Nasogastric tube should be passed and proper caloric
requirement of the patient should be maintained.
Pass orogastric tube in cases of skull base fracture and

CSF leak
Skin Care
Posture should be changed every 2 hours
to prevent bed sores.
Mouth Wash
Oral cavity should be cleaned regularly.
Bowel and Bladder Care Patients

should be catheterized and bowel
evacuation should also be considered.
DVT prophylaxis should be provided

Past Paper Question
Q.Write down the

Glasgow comma scale
for the assessment of
head injury. A-15
Past Paper Question
Q.A 30 years old patient was brought to ER department
after road traffic accident with decreased conscious level.
He was resuscitated as per ATLS protocol.
Write motor and verbal response component of Glasgow

Coma Scale.
b) Mention four guidelines for obtaining CT brain plain in

patients with head injury A-21
Past Paper Question
Q.A patient brought in emergency after road traffic accident. On

examination, his eyes are opens, answering your questions and
obeying your commands regarding motor movements of limbs.
What is the Glasgow coma score of this patient?
b) Write down the signs of base of skull fracture. A-23

Any Question?

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Neurosurgery

Head and scalp injury

MIT ,RMU (Batch 13)

if not controlled these

Injuries to skull are a result of crushing or other severe forces.

Fractures of skull may be linear or depressed .

A depressed fracture of the vault may cause extradural or subdural haematoma.

2.Cranial nerves 4.CSF

Bleeding from ears

Cranial nerves injury:

Bruise over the

Follow the guidelines provided by ATLS (A, B, C, D)

Nasogastric tube should never be attempted in emergency department in

Linear fractures are usually managed conservatively

Depressed bone fracture can be left as such if it is not deeply

It should be elevated if depression is greater than skull bone thickness or

Brain injury can be divided into primary and Secondary injuries.

Primary Brain Injury is the direct result of trauma

Which may occur at the site of impact (Coup injury) or as an extensive

It includes concussion, bone fragmentation, axonal injury and brain stem

Diffuse Axonal injury:

It results from sheering of grey-white matter interface, causes microscopic

This is a clinical diagnosis and is defined by a period of amnesia

Cerebral contusion and laceration: These are visible as small areas of

It occurs after the initial injury

It occurs due to Hypoxia, hypercapnea, and hypotention (Ischemia), intra

This is the main cause of hospital mortality after head injury.

This rise in intra cranial

Cerebral Perfusion =B. P –

This decrease in cerebral perfusion pressure can results in cerebral ischemia.

The resultant ischemia of cardio respiratory centre leads to reflex increase in

Patient may present with headache, projectile vomiting, hypertension and

Head injury is managed following the guidelines

Primary Survey and Resuscitation

This includes airway, breathing, circulation, disability and exposure.

or manipulation as partial injury of cervical cord can be changed to complete injury by

It includes head to toe examination and thorough neurological assessment is

Mild head injury (GCS: 3-8)

Moderate head injury (GCS: 9-13)

(Severe head injury=(GCS: 14 – 15)

3 Words, but not coherent

3-Abnormal flexion response or decorticate posture

extension response, Decerebrate

It should be cause oriented and is described below

Mannitol: 1g of 20% I/V bolus and 6hrly is effective in

Hyperventilation: It is used to wash out

Any extradural or subdural hematoma

The depressed bone can be left as

Which can be controlled by

I/V lorazepam 1mg bolus.

Pass orogastric tube in cases of skull base fracture and

Bowel and Bladder Care Patients

DVT prophylaxis should be provided

Q.Write down the

Write motor and verbal response component of Glasgow

b) Mention four guidelines for obtaining CT brain plain in

Q.A patient brought in emergency after road traffic accident. On

What is the Glasgow coma score of this patient?

b) Write down the signs of base of skull fracture. A-23

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