Group 5 & 7

CASE :
A 40 year old male brought into the ER with a chief
complaint of headache after a motor vehicle crash.
The patient was conscious upon arrival at the ER.
Vital signs
PR : 77 bpm
RR : 18 cpm
BP : 110/80 mm Hg
Temp : 37.5°C

The patient is stable and has no life-threatening conditons.

Primary survey history

• NOI: Motor Vehicle Crash.

• TOI : 8 am
• DOI : 26-Feb-2019
• POI : outside DMSF
PRIMARY SURVEY PHYSICAL EXAMINATION

1. AIRWAY: Clear and patent, no obstruction , no evident

facial bone fractures
2. BREATHING:-
• Inspection: symmetrical chest expansion ,no
paradoxical chest movement
• Palpation: (-) tenderness
• Percussion: (+) resonant in both lung fields.
• Auscultation: decreased breath sounds in right
lung and clear breath sounds in left lung.
• Pneumothorax noted on right lung based on the
PE findings & was corrected by performing CTT.
3. CIRCULATION: BP 123/78 (Normal), O2sat
98%(normal), PR 78(normal) ,no sites of bleeding from
chest , abdomen ,pelvis & extremities
4. DISABILITY: GCS score was 15 . Patient is alert,
conscious and responsive
5.EXPOSURE : no other injuries noted on exposing the
patient.

The patient is stable and has no life-threatening conditons.

INITIAL IMPRESSION :-
Mild traumatic head injury secondary to motor
vehicular crash.
SECONDARY SURVEY

History Of Present Illness

2 hours PTC, patient was riding a motor cycle alone without
wearing helmet at an unrecalled speed and met with a motor
vehicular crash when he hit on a cow and was thrown away and hit
his right side of head on a rock and lost his consciousness. The patient
was not under the influence of alcohol as claimed. There were no
associated symptoms.

Upon arrival at E.R the patient had Headache which was

throbbing, non-radiating and continuous in character with severity of
5/10 in pain scale. Patient also had left sided weakness.
Past Medical History:
No known illness, No maintenance Medications,
No previous hospitalization, No allergies.

Family history: No heredofamilial diseases like Asthma,

Hypertension, Diabetes or Cancer

Personal and social History: Nonsmoker, Non alcoholic

drinker, No illicit Drug abuse.
Physical Examination :

General: The patient was awake, fully coherent, NIRD.

Vital signs: Stable vitals and no Life-threatening conditions
Head: No swelling or laceration noted
Eyes: The pupils are symmetrical and equally reactive tolight. No
raccoon sign noted.
Ear: No bleeding, No battle sign or discharge noted
Nose: Symmetrical, No epistaxis, No rhinorrhea,
Throat: No obstruction noted, No Inflammation noted, No tonsil
enlargement.
Chest: Inspection: Symmetrical, No scars or retractions noted, no flail
chest.
Palpation: No Fractures of clavicles or Ribs noted.
Percussion: Resonant on both right and left side
Auscultation: Clear Breath Sounds bilaterally
Extremeties : No edema, no bruise or ecchymoses noted

Neurologic exam :
Neurologic: GCS- 15 .Patient was awake, Oriented to
Time and place
Motor Exam: Patient had Left sided weakness.
Sensory: Intact Sensorium.

The patient lost his conscious after performing P.E

Vital Signs were stable with no life-threatening
conditions
 DIFFERENTIAL DIAGNOSIS

DDX RULE IN RULE OUT

EPIDURAL HEMATOMA • Initial loss of
consciousness
• Presence of Lucid
interval
• Loss of conscious after
lucid period
• Headache
• Left sided weakness
SUBDURAL HEMATOMA • Confusion
• Headache
• Hemiparesis
SUBARACHNOID • Sudden headache Headache pain scale 5/10
HEMARRHAGE • Confusion
• Hemiparesis
DIFFUSE AXONAL INJURY • Headache
• Loss of consciousness
Imaging

• Cranial CT -bright blood

clot,covex in shape on Right
fronto-temporal lobe with well
defined border that usually
respects cranial suture lines
and cresent shaped blood
clot in left fronto-temporal
lobe with poorly defined
margin.
 FINAL IMPRESSION

Mild traumatic head injury secondary to motor

vehicular crash with right frontal lobe epidural hematoma
with left frontal lobe subdural hematoma
 Medical order
• Please admit the patient under in Surgery ward.
• Secure consent for care.
• Diet: NPO
• IVF : plain LR 1L 120cc/hr every 8 hrs.
• Therapeutics:
tramadol 50mg IV every 6 hours as required for pain.
Omeprazole 40 mg IVTT OD
Mannitol 1.5g/Kg IV over 60mins
• Labs: Plain CT scan head ,CBC w/ Plt, ABG
• Insert NGT and Foley catheter.
• Monitor I & O every shift
• Monitor Vitals Q4
• Please relay labs once available.
• Please Refer accordingly.
• Thank you.
 DISCUSSION
CLOSED HEAD INJURY
• Closed head injury (CHI) is the most common type
of TBI.
• There are two important factors that affect the
outcome of CHI in general. The initial impact causes
the primary injury.
• Subsequent neuronal damage due to the sequelae
of trauma is referred to as secondary injury.
SUBDURAL HEMATOMA
ACUTE VS CHRONIC SUBDURAL

HEMATOMA
 INDICATIONS FOR OPEN CRANIOTOMY
ACUTE SDH
• THICKNESS> 1CM
• MIDLINE SHIFT >5mm
• GCS DROP BY TWO OR MORE POINTS FROM THE
TIME OF INJURY TO HOSPITALIZATION
• Non operatively managed hematomas may stabilize and
eventually reabsorb or evolve into chronic SDH
• MANAGEMENT : requires frequent neurological
examination until the clot stabilise on serial head CT scan
 CHRONIC SDH
A chronic SDH >1 cm or any symptomatic SDH should be
surgically drained
• A simple burr hole can effectively drain most chronic SDH
• THE PROCEDURE IS CONVERTED TO OPEN
CRANIOTOMY IF THE SDH is too congealed for irrigation
drainage
There are various stratiges to prevent reaccumulation of blood
1. subdural or subgaleal drain may be left in place for 1 to
2 days
2. mild hydration and best rest with the head f bed flat
3. high level of insipred oxygen to draw nitrogen out of
cavity
4. follow up CT scan postop and approx 1 month later to
document resolution
 EPIDURAL HEMATOMA
• EDHs are associated with lower-
energy trauma with resultant
primary brain injury
• EDH is the accumulation of blood
between the skull and the
dura(periosteal layer).
• EDH usually results from arterial
disruption, especially of the middle
meningeal artery.
• As the volume of the hematoma
grows, the decompensated region of
the pressure-volume curve is
reached, ICP increases, and the
patient rapidly becomes lethargic
and herniates.
 PATHOPHYSIOLOGY OF EPIDURAL HEMATOMA

Direct blow or coup and contre-coup injuries

↓
Fracture of thin squamous part of temporal bone
↓
Tear of middle meningeal artery
↓
Formation of haematoma between the skull and the dura
↓
In 6-12 hours epidural haematoma occurs which raises the
intracranial pressure
↓
Uncal herniation
↓
Ipsilateral CN III palsy and contrlateral hemiparesis
 Concussion

• Temporary neuronal dysfunction

following nonpenetrating head trauma.
• The head CT is normal, and deficits
resolve over minutes to hours.
• Transient loss of consciousness,
alteration of mental status, Memory
difficulties, especially amnesia of the
event, are very common.
• Colorado grading system :
Grade 1 : Confusion only
Grade 2 : Amnesia
Grade 3 : Lose consciousness
 Contusion
• Bruise of the brain occuring when the
force from trauma is sufficient to cause
breakdown of small vessels and
extravasation of blood into the brain.
• The contused areas appear bright on CT
scan. The brain sustains injury as it
collides with rough, bony surfaces.
• Edema may develop around a contusion,
causing mass effect. Contusions may
enlarge or progress to frank hematoma,
particularly during the first 24 hours.
• Contusions occuring in brain tissue
opposite the site of impact is known as a
contre-coup injury.
Hematoma
EPIDURAL SUBDURAL
type

Between the Between the

Location skull and dura and
the dura the arachnoid
Middle meningeal
Involved vessel Bridging veins
artery
Gradually
Lucid interval
increasing
Symptoms followed by
headache and
unconsciousness
confusion
Appearance on Convex(lentiform) Crescent(lunate)
CT shaped shaped
Labs / Imaging

• Cranial CT scan (+/- Contrast)

• CBC(Plt,BT,PT,APTT)
• Serum electrolytes(Na,K) and Creatinine
• Skull series (APL and C-spine views)

.
 Managment

• For conservative managment -clot volume<30cm³,maximum

thickness<1.5cm,and GCS score >8.
• Open craniectomy -for evacuation of congealed clot and
hemostasis.
• Trephination or making a burr hole is a surgical intervention in
which a hole is drilled into the human skull, exposing the dura
mater to treat health problems related to intracranial diseases
or release pressured blood buildup from an injury
INDICATIONS FOR SURGERY
It is based on
• Clot volume
• Amount of midline shift
• Location of clot
• GCS score
• ICP

1) EPIDURAL HEMATOMA
~ Clot volume >30 cm cube
~ Maximum thickness > 1.5 cm
~ GCS score < 8
2) SKULL FRACTURES

~ Depression greater than Cranial thickness

~ Intracranial hematomas
~ Frontal sinus involvement

3) INTRAPARENCHYMAL HEMORRHAGE

~ Clot volume >50 cm cube or clot volume > 20 cm cube

with referable neurologic deterioration (GCS 6-8)
~ Midline shift > 5mm or basal cistern compression.
MEDICAL MANAGEMENT :

• Several medical steps may be taken to minimize

secondary injury and the systemic consequences of head
injury.
• Patients with a documented CHI and evidence of
intracranial haemorrhage or a depressed skull fracture
should receive a 17-mg/kg phenytoin loading dose,
followed by 1 week, typically 300-400 mg/d.
• Phenytoin prophylaxis decreases the incidence of early
post-traumatic seizures.
• Blood glucose levels should be closely monitored by
capillary blood sugar checks..
• Fevers also should be evaluated and controlled with
antipyretics.
• Hyperglycemia and hyperthermia are toxic to injured
neurons and contribute to secondary injury.
• Ulcer prophylaxis should be used for Head injured patients.
• Compression stockings or athrombic pumps should be used
when the patient cannot be mobilized rapidly for prophylaxis
of deep venous thrombosis.