Head injury and medical tratment

HEAD INJURY & MEDICAL TREATMENT

Head injury-hidden epidemic

• Traumatic brain injury (TBI) / head injury occurs when a sudden trauma, such as a blow to the head, causes damage to the brain. • Such injuries can result in impaired physical, cognitive, emotional, and behavioral functioning.

INDIAN SCENARIO• Major health problem in India due to greater growth and development in terms of motorization, urbanization.• It is estimated that nearly 1 million persons are injured, 200,000 people die and nearly 1 million require rehabilitation services every year in India.• In India, 60%–70% of TBI results from Road Traffic Accidents (RTA)• It has been reported that India has the highest mortality rates from RTA in the world, with 161,736 RTA deaths in 2010

Abhijit Das et al Neurology 79 November 20, 2012

Causes of head injury

• Automobile accidents, (Under age of 75)• Falls (Above age of 75)• Assaults/blows, • Sports-related injuries, • Explosive blasts

TYPES OF HEAD INJURY

• Scalp lacerations• Skull fractures• Minor Head Trauma: Concussion and post-concussion syndrome • Major Head Trauma: Cerebral contusion, Laceration

TBI review National Institute of Neurological Disorders and Stroke National Institutes of Health

Skull fractures

• Linear Skull Fracture • Depressed Skull Fracture • Diastatic Skull Fracture • Basal Skull Fracture • Compound Skull Fracture• Compound elevated Skull Fracture • Growing Skull Fracture

Skull fracture-contusion• Skull fractures occur when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. A penetrating skull fracture occurs when something pierces the skull, such as a bullet, leaving a distinct and localized injury to brain tissue.• Skull fractures can cause bruising of brain tissue called a contusion. A contusion is a distinct area of swollen brain tissue mixed with blood released from broken blood vessels.

Traumatic Brain Injury: Hope Through Research,” 2002, NINDS

concussion• Concussion is the most minor and the most common type of TBI. Technically, a concussion is a short loss of consciousness in response to a head injury


contrecop

• A contusion can also occur in response to shaking of the brain back and forth within the confines of the skull, an injury called “contrecoup.” • This injury often occurs in car accidents after high-speed stops and in shaken baby syndrome, a severe form of head injury that occurs when a baby is shaken forcibly enough to cause the brain to bounce against the skull.


Hematoma

• Damage to a major blood vessel in the head can cause a hematoma, or heavy bleeding into or around the brain. • Three types of hematomas can cause brain damage.1. Epidural hematoma involves bleeding into the area between the skull and the dura. 2. In subdural hematoma, bleeding is confined to the area between the dura and the arachnoid membrane. 3. Bleeding within the brain itself is called intracerebral hematoma. Traumatic Brain Injury: Hope Through Research,” 2002,

NINDS

SYMPTOMS OF POST-CONCUSSION SYNDROME

• The most common symptoms after head injury are known as post-concussion syndrome (PCS).

Diagnostic measure

• Skull and neck X-rays• CT scan• MRI• Intracranial pressure monitoring• Electroencephalography(EEG)• Nerve conduction velocity (NCV)• Electronystagmography

Complications • Coma• Paralysis• Chronic headache• Loss/change in sensation, hearing, vision, taste or smell• Paralysis• Speech problem• Seizure• Death

Assessment after stabilization

As soon patient get stabilized, assess the patient’s condition by measuring • vital signs and reflexes and by performing a neurological examination.• Temperature, blood pressure, pulse, breathing rate, and pupil size in response to light.• The level of consciousness as assessed by the Glasgow Coma Scale has been used to categorise the severity of a head injury


Glasgow coma scale

Indications for referral to hospital

• GCS<15 at initial assessment• Post-traumatic seizure � (generalised or focal)• Focal neurological signs�• Signs of a skull fracture � (including cerebrospinal fluid from nose or ears, haemotympanum, boggy haematoma, post auricular or periorbital bruising)• Loss of consciousness�• Severe and persistent headache�• Repeated vomiting � (two or more occasions)• Post-traumatic amnesia >5 minutes�• Retrograde amnesia >30 minutes�• High risk mechanism of injury � (road traffic accident, significant fall)• Coagulopathy, whether drug-induced or otherwise.�

Supportive Measures• Endotracheal intubation for patients with decreased level of consciousness and poor airway protection. • Cautiously lower blood pressure to a MAP less than 130 mm Hg, but avoid excessive hypotension.• Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan. • Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema • Avoid hyperthermia. • Facilitate transfer to the operating room or ICU.Harrison’s internal medicine 17th edition

Initial management

• A: airway• B: breathing• C: circulation• D: dysfunction/disability• E: external management

Harrison’s internal medicine 17th edition

Decrease cerebral edema• Modest passive hyperventilation to reduce PaCO2 • Mannitol, 0.5-1.0 gm/kg slow iv push • Furosemide 5-20 mg iv • Elevate head 20-30 degrees, avoid any neck vein compression • Sedate and paralyze if necessary with morphine and vecuronium (struggling, coughing etc will elevate intracranial pressure)


Medical therapy• Antihypertensives - reduce blood pressure to prevent exacerbation of intracerebral hemorrhage in hypertensive encephalopathy. Eg Nicardipine, labetolol; CCB helps to relieve vasospasm in SAH and decrease further damage • Diuretics - Mannitol, CAI • Anticonvulsants – reduce frequency of seizures and prophylaxis of seizures eg: Fosphenytoin • Antipyretics- to Rx fever and pain relief eg: Acetaminophene • Antidote- VitK/FFP for warfarin overdose; protamine for heparin overdose • Antacids- prophylaxis for Cushing’s gastric ulcer eg: Famotidin • Glucorticoids may help reduce the head and neck ache caused by the irritative effect of the subarachnoid blood.


Diet plan

• Protein is used for almost all tissue repair of the body• Those with head injury require 0.55 to 0.73 gm of protein per pound of body weight• Someone with a GCS of 4 to 5 needs 22.7 to 27.3 calories per pound of body weight per day.• Someone with a GCS of 6 to 7 needs 18.2 to 22.7 calories• Those with less-severe injuries who have a GCS of 8 to 12 require 13.6 to 16 calories.

SAFETY TIPS

• Wear a seatbelt every time you drive or ride in a car.• Wear a helmet while riding• Make sure the surface on child’s playground is made of shock-absorbing material• Keep firearms and bullets stored in a locked cabinet when not in use


Documents

Head injury and medical tratment