HEAD INJURIES

RV M OLLERO MD

Diplomate, Philippine Board of Emergency Medicine

Fellow, Philippine College of Emergency Medicine and Acute Care
International Member, American College of Emergency Physician 410603
 HEAD INJURIES
 involve the scalp, skull, underlying
brain & blood vessels
 may be focal or diffuse
 Mortality Rate
• associated with approximately 50% of trauma deaths
• with MR approaching 35% in patients with severe
head injuries
• Inpatients with severe head injuries, the initial score
on the Glasgow Coma Scale and the type of lesion
responsible for the neurologic deficits are good
indicators of outcome
 Pathology
• Unconsciousness
– Induced by either:
• bilateral cerebral cortex injury or
• injury to the reticular activating system
 Pathology
• Increased Intracranial Pressure
– results from increased intracranial volume either
from a mass (hematoma) or edema
– can lead to altered level of consciousness, coma,
hypertension, bradycardia (Cushing’s
phenomenon) and finally death
 Pathology
• Herniation Syndrome
• Cerebral Perfusion Pressure Derangements
 Herniation Syndrome
(focal or diffuse increases in ICP)

• Subfalcial herniation
• Uncal herniation
• Cerebral tonsillar herniation
 Herniation Syndrome
(focal or diffuse increases in ICP)

• Subfalcial herniation
– From one cerebral hemisphere protruding
beneath the falx cerebri into the opposite
supratentorial space
 Herniation Syndrome
(focal or diffuse increases in ICP)

• Uncal herniation
– increased ICP causes the uncus of the temporal lobe to
protrude through the opening of the tentorium between
the cerebral peduncle and the tentorium
– causes compression of the
• ipsilateral third cranial nerve
• ipsilateral corticospinal tract within the cerebral peduncle
• brain stem
 Herniation Syndrome
(focal or diffuse increases in ICP)

• Uncal Herniation
– Clinical Signs
• ipsilateral fixed dilated pupil
• contralateral hemiparesis
• deteriorating level of consciousness
– True Neurosurgical Emergency
 Herniation Syndrome
(focal or diffuse increases in ICP)

• Cerebellar Tonsillar Herniation

– Through the foramen causes
• compression of the medulla
• bradycardia
• slowering of the respiration
• and death
 Cerebral Perfusion Pressure
Derangements
• Cerebral perfusion pressure is the mean
arterial pressure minus the ICP
• Autoregulation of cerebral blood flow may be
lost either focally or globally if the ICP remains
persistently high
 Clinical Features
• Diffuse Brain Injuries
– Concussion and diffuse axonal injuries
• Focal Lesions
– subarachnoid hemorrhage
– epidural hemorrhage
– penetrating head injuries
– GSW
– impalement injuries
– skull fracture
– scalp lacerations
– brain contusions
 Diffuse Brain Injuries
• Concussion
– Transient loss of consciousness or other
neurologic function that lasts for a few seconds or
minutes
– Occurs immediately after blunt head trauma
– causes impairment of the reticular activating
system and there are typically no permanent
sequelae
 Diffuse Brain Injury
• Concussion
– Post concussive Syndrome
• Headache
• Decreased memory and attention
• Insomnia
• Dizziness that persist
 Diffuse Brain Injury
• Diffuse Axonal Injury
– Mortality rate 35 – 50%
– Secondary to shearing or tearing of nerve fibers
– Characterized by coma in the absence of a focal lesion
– Autonomic dysfunction
• Increased blood pressure
• Increased temperature
• sweating
 Focal Lesions
• Subarachnoid hemorrhage
• Subdural hematoma
• Epidural hematoma
• Penetrating head injury
• Skull fracture
• Scalp Laceration
• Brain contusion
 Subarachnoid Hemorrhage

• most common site of

bleeding after head
trauma
• results in bloody CSF
• complain of
Headache and
photophobia
 Subdural Hematoma
• accounts for approximately
30% of severe head injuries
• collection of blood lying
between the dura and the
arachnoid mater
• (below dura and over the
brain)
• results from tearing of the
bridging veins traversing the
subdural space
• acceleration – deceleration
mechanism
• neurologic deficit
• mass effects - hematoma
• contussion of the underlying
brain
 Epidural Hemorrhage
• 1% of head injuries
• results from tearing of a dural artery
• collection of blood between dura and the skull
• suspected in patients with skull fracture
involving the temporal bone
• middle meningeal artery passes between the dura and
the skull
 Epidural Hemorrhage
• classically characterized by a
– brief initial period of uncounsciousness, a lucid
interval lasting few minutes to hours and
subsequent deterioration in neurologic status
secondary to increasing ICP
» “lucid interval” where they talk and die
• requires Early Neurosurgical involvement
Computation of Hematoma volume
(Kothari Method)

Hematoma vol (cc) = AxBxC

2

Where:
A: largest diameter of hematoma (cm)
B: Diameter perpendicular to A (cm)
C: Number of slices on CT scan x slice thickness (cm)
Count slice as 1 if size of hematoma is > 75% of largest hematoma
Count slice as 0.5 if size of hematoma is 25% to 75% of
largest hematoma
Disregard slice if size of hematoma is < 25% of largest hematoma
 Penetrating Head Injury
• Usually obvious in its presentation
• Associated with high mortality rate
• Radiographs can help to identify the degree of
penetration and path of the object
• Any impaled object should be left in place
until surgical removal can be accomplished
 Skull Fracture
• Linear
• Stellate
• Depressed
• Basilar
• Open
 Linear Skull Fracture
• Becomes clinically important if it occurs over
the:
– middle meningeal artery groove
– major venous dural sinuses (formation of an
epidural hematoma)
– air-filled sinuses
– associated with underlying brain injury
 Stellate Skull Fracture
• Suggestive of a more severe mechanism of
injury than linear skull fractures
 Depresses Skull Fracture
• Carries a greater risk of
underlying brain injury
and complications
(meningitis, post-
traumatic seizures)
• Treatment involved
surgical elevation for
depressions greater than
the thickness of the
adjacent skull
 Basilar Skull Fracture
• Often a clinical diagnosis and sign of a significant
mechanism of injury
• Signs include
– periorbital ecchymosis (raccoon’s eye)
– retroauricular ecchymosis (Battle’s sign)
– otorrhea
– rhinorrhea
– hemotympanun
– cranial nerve palsies
 Open Skull Fracture
• A laceration overlying a skull fracture
• Requires careful debridement and irrigation
• Avoid blind digital probing of the wound
• Obtain neurosurgical consultation
 Scalp Lacerations
• Scalp consist of five layers
» Skin
» Connective tissue
» Aponeurosis (galea)
» Loose areolar tissue
» pericranium
• Highly vascular structure
• source of major blood loss
• loose attachment between the galea and the pericranium
• allows for large collection of blood - subgaleal hematoma
• Disruption of the galea should be corrected
• single-layer
• interrupted 3.0 nonabsorbable sutures
• through the skin, subcutaneous tissue and galea
 Cerebral Contusion
• Occurs when the brain impacts the skull
• May occur directly under the site of impact
(coup) or on the contralateral side
(contrecoup)
• Focal defecits ranges from confusion to coma
 Differential Diagnosis
• Causes of altered Level of Consciousness after
head injury
• Hypoglycemia
• Hypoxia
• Hypotension
• Hypothermia
• Alcohol and other drugs
• Electrolyte abnormalities
• Metabolic abnormalities
 Evaluation
• Physical Examination
• Diagnostic Imaging Studies
• Laboratory Studies
 Physical Examination
• Primary Survey – “ABCs”
• Pupillary size and reactivity
• Baseline mental status
• Odor of alcohol on the breath
• Cervical spine
 Physical Examination
• Secondary Survey
– Head Examination
– Depressed fractures
– Open fractures
– Otorrhea or rhinorrhea
– Tympanic membrane – hemotympanum
– Periorbital hematoma “racoon’s eye)
– Mastoid area – ecchymosis “Battle’s Sign –basilar skull
fracture
 Physical Examination
• Secondary Survey
– Neurologic Examination – complete
• Lateralizing signs
• Altered pupils
• Deteriorating mental status

– Should be performed at frequent intervals to

search for changes from initial examination
 Physical Examination
• Secondary Survey
– Glasgow Coma Scale
• for classifying head injury
– Severe head injury : GCS 8 or less
– Moderate head injury : GCS 9 to 13
– Mild head injury : GCS 14 or 15
 Glasgow Coma Scale
• Eyes
• Open spontaneously 4
• Open to verbal command 3
• Open to pain 2
• No response 1
• Best Motor Response
• Obeys Verbal command 6
• Localizes pain to painful stimulus 5
• Flexion withdrawal 4
• Decorticate Rigidity 3
• Decerebrate Rigidity 2
• No response 1
• Best Verbal Response
• Oriented and converses 5
• Disoriented and converses 4
• Inappropriate words 3
• Incomprehensible souns 2
• No response 1

• Total 15
 Vital Signs
• Should be closely assessed especially noting
hypertension and bradycardia in the setting of
increased ICP (Cushing’s phenomeneon)
• Cushing Refelex is the brain’s attempt to maintain CPP
 Treatment
• Initial Stabilization
• Lowering the ICP
• Treatment of Seizures
• Treatment of Scalp Wounds
• Emergent Neurosurgical consultation
 Diagnostic Imaging Studies
• CT
• Loss of consciousness or amnesia
• persisting depression or worsening of mental status
• Abnormal neurologic examination findings
• Seizures
• Moderate to severe mechanism of injury
• Depressed skull fracture or linear fracture overlying a dural venous
sinus or meningeal artery groove
• Skull radiographs – largely been replaced by CT scan
• Penetrating head injury
• Possible depressed skull fracture
 Laboratory Studies
• Initial glucose level and oxygen saturation
level
» rule out factors contributing to altered mental status

• ABG
• Serum electrolyte
• Alcohol and toxicology screen
• Coagulation studies
 Initial Stabilization
• Fluid Resuscitation
• Hypotensive – intravenous fluid adequate to maintain
blood pressure
• Avoiding overhydration if increased ICP
• Adequate Oxygen and Glucose levels
 Lowering the ICP
• Hyperventilation
– GCS ≤ 8
– intubation
– PC02 = 25 – 30 mm Hg
– cerebral vasoconstriction
– helps decrease ICP
– Prolonged and aggressive
– decreased cerebral perfusion
• Additional treatments
– Elevation of the head
– Sedating the patient
– Administration of Mannitol and furosemide
 Treatment of Seizures
• Pheyntoin with or without Benzodiazepines
– Adults
• 1 gram infused at 50 mg/min
– Children
• 15 mg/kg at 0.5 – 1 mg/kg/min not to exceed 50
mg/min
 Treatment of Scalp Wounds
• Copius irrigation
• Pressure applied to control bleeders
• Wound should be closed in a single layer with
suture or staples
• Tetanus prophylaxis
 Emergent Neurosurgical Consult
• Patients with lateralizing sign
• Large focal mass lesion
• Any signs of herniation

• Evacuation of hematoma, placement of burrhole or a

ventriculostomy

• SAH of traumatic origin does not usually require

intervention other than admission for observation
 Disposition
• Discharge
– With minor head injury GCS 15
– No loss of consciousness
– Head instruction reviewed with patient and family
members
– Advised to watch for persistent
• Headache
• Vomiting
• Dizziness
• Alteration in metal status
• Other signs of deteriorating neurologic function
 Disposition
• Admission
– Loss of consciousness or unreliable follow-up
– Severe head injury – admission to an ICU