Head injury is one of the commonest form of trauma in urban settings. Prompt diagnosis of the underlying damage followed by immediate treatment is the mainstay of treatment.

1. Head Injuries
Dr. Ketan Vagholkar
M.S.(BOM)., D.N.B., M.R.C.S.(GLASGOW)., F.A.C.S.
Consultant General Surgeon & Professor of Surgery

2. Head Injuries
Learning Objectives
v Understanding the basic sciences related
to pathophysiology of head injuries
v Clinical evaluation
v Management
v Medicolegal documentation

3. Pathophysiology
• Monro Kellie
Hypothesis.
• Cerebral Edema
vasogenic-bbb affected
cytotoxic-bbb unaffected
osmotic-bbb intact
interstitial- csf brain barrier affected
• Conning
subfalceal
trans tentorial- Kernohans notch
trans foramen magnum

4. Primary management of trauma
patient
• Airway
• Breathing
• Circulation
• Clinical assessment

5. Clinical Features
• History • PhysicalExamination
Mechanism of injury/impact, Pulse
Unconsciousness, Blood pressure
Vomiting, Respiratory rate
Convulsions, Glasgow coma scale
ENT bleed,
Alcoholism, • Local examination of the head
Diabetes, for scalp injuries & depressed
Hypertension, fractures
TIA’s

6. Glasgow Coma Scale

7. • Detailed
documentation of vital
and neurological
parameters

8. Neurological Examination
• Position of patient
• Depth of unconsciousness
• Eyes ; Black eye (Periorbital ecchymosis)
: Pupils – size, equality and reaction to light
• Examination of ears and nose for blood or csf leak
• Power in the limbs and reflexes
• Cranial nerves
• Examination of neck

9. Coup and Contre- coup injuries
• Scalp laceration • -
• Skull fracture • -
• Extradural hematoma • -
• Subdural hematoma • Subdural hematoma
• Cerebral laceration and • Cerebral laceration and
contusion contusion
• Brain edema • Brain edema
• Intracerebral hematoma • Intracerebral hematoma

10. Examination of Neck
• Every head injury patient is assumed • Cervical (neck) injuries usually result in full or partial
tetraplegia (Quadriplegia). However, depending on
to have sustained a neck injury unless the specific location and severity of trauma, limited
proved otherwise hence detatiled function may be retained.
evaluation of neck for injuries is pivitol • Injuries at the C-1/C-2 levels will often result in loss
of breathing, necessitating mechanical ventilators or
phrenic nerve pacing.
• C3 vertebrae and above : Typically results in loss of
diaphragm function, necessitating the use of a
ventilator for breathing.
• C4 : Results in significant loss of function at the
biceps and shoulders.
• C5 : Results in potential loss of function at the
shoulders and biceps, and complete loss of function
at the wrists and hands.
• C6 : Results in limited wrist control, and complete
loss of hand function.
• C7 and T1 : Results in lack of dexterity in the hands
and fingers, but allows for limited use of arms.
• Patients with complete injuries above C7 typically
cannot handle activities of daily living and cannot
function independently.[citation needed]
• Additional signs and symptoms of cervical injuries
include:
• Inability or reduced ability to regulate heart rate,
blood pressure, sweating and hence body
temperature.
• Autonomic dysreflexia or abnormal increases in
blood pressure, sweating, and other autonomic
responses to pain or sensory disturbances.

11. Other Examinations
• Thorax
External injuries
Movements of the chest
Auscultation of the chest
• Abdomen
External injuries
Tenderness, rebound tenderness
Guarding , rigidity
4 quadrant tap if required
Skeletal examinations
Limb fractures

12. Admission to hospital for all head
injury patients is a safe practice
• Always give a equivocal or a accurate picture regarding
the severity of injury and a uncertainty regarding the
variable outcome to avoid illusion in the minds of the
relatives
• Close observation of neurological status
• Early detection of neurological deterioration and avoiding
delay in neurosurgical intervention
• Allays the anxiety of relatives
• Quick transfer to a neurosurgical facility if in a peripheral
hospital
• Medico legally safe and defensive for the attending
clinician

13. Investigations
• Hematological • Radiolgy
CBC • Plain CT scan of brain
Blood sugar levels • Cervical spine x-ray preferably
BUN in all head injury patients
Creatinine • 3D CT scan of the skull in
Electrolytes suspected facial bone fractures
Blood grouping in severe cases • Plain x-rays depending upon
the injuries e.g. open mouth
Toxicology scan in suspected view, nasal spine, paranasal
drug ingestions sinuses,

14. Treatment Objectives
• Treatment of raised intracranial tension
due to cerebral edema
• Treatment /prevention of convulsions
• Treatment of scalp injuries
• Treatment of skull fractures
• Treatment of intracranial hematomas

15. Treatment of raised intracranial
tension due to cerebral edema
• Elevation of the patient’s head to promote venous
drainage
• Hyperventilation if GCS greater than 5
• Increasing the serum osmolality to approx 300-310
mOsm/lit by administering mannitol ( in adults bolus
dose of 1 gm followed by maintainance dose of 0.25-
0.50 gms evey 6 hourly) however the effect remains for
not more than 48 hours
• Loop diuretics such as lasix in patients with comorbid
problems
• Barbiturates as the last resort, best given in a
neurosurgical facility

16. Treatment /prevention of
convulsions
• Eptoin sodium is the drug of choice
• In patients who have had a convulsion
Loading dose of 300mgms followed by maintenance dose of 100mgms every 8
hourly converted to oral dosage at discharge and continued for 2 years
• In patients who have not convulsed but
have intracranial pathology
Prophylactic dosage of 100mgm every 8 hourly converted to oral dosage at the
time of discharge and continued for a period of 6 months

17. Treatment of scalp injuries
• Shave the surrounding hair to have minimum clearance of 1 inch all
around the wound
• Rigourous cleansing of the wound ensuring complete removal of all
foreign materials
• Adequate hemostasis of bleeding scalp vessels by eversion of scalp
layers or by pressure tamponade
• Exact assessment of the depth of the wound with regards the layers
of the scalp and if breached whether aponeurosis breached or intact
• Limited debridement only in badly contused and irregularly lacerated
wounds.
• Chromic catgut 1-0 for aponeurosis suturing
• Prolene or ethilon 1-0 for skin and superficial layers of scalp
• Antibiotics, analgesics and tetanus prophylaxis

18. Treatment of skull fractures
• Linear fracture- conservative treatment
• Depressed fracture- requires surgery if significantly
depressed
• Diastatic fractures which involve sutures usually
lambdoid - conservative treatment
• Basilar fractures- conservative tratment- if CSF leak
persist than osteoplastic flap surgery at a latter date
• Compound skull fractures- conservative treatment to
start with followed by surgical intervention at a latter date
if required.

19. Treatment of intracranial
hematomas
• Extradural Hematoma
LocationBetween the skull and the dura
Involved vessel
Temperoparietal locus (most likely) - Middle meningeal artery
Frontal locus - anterior ethmoidal artery
Occipital locus - transverse or sigmoid sinuses
Vertex locus - superior sagittal sinus
SymptomsLucid interval followed by unconsciousnessCT
AppearanceBiconvex lens
Treatment Exploratory craniotomy with evacuation of the hematoma

20. Treatment of intracranial
hematoma
• Subdural Hematoma
Lcation ;Between the dura and the arachnoid
Involved vessel Bridging veins
Symptoms Gradually increasing headache and confusion
( acute,subacute and chronic presentation)
Appearance Crescent-shaped
Treatment craniotomy with evacuation of hematoma

21. Treatment of intracranial
hematoma
• Intracerebral hematomas have very poor
prognosis
• Surgical debridement may be attempted in
a few cases but with poor results
• Post traumatic Subarachnoid hemorrhage
is treated conservatively and has doubtful
prognosis.

22. Late Complications of head injuries
• Post traumatic headache
• Post-traumatic epilepsy
• Hydrocephalus
• Memory Changes

23. Medicolegal documentation
• Note should be made about the informant
• Detail list of injuries along with diagrams is strongly advised
• Dimensions in cms should be mentioned
• Injury certificate should contain clinical examination injury findings as well
as lesions picked on Ct or any other radiological examination.
• While in hospital the level of consciousness (GCS) and vital parameters
should be documented on a periodic basis till the patient achieves
neurological and hemodynamic stability
• All short term and long term sequelae of the lesion should be explained to
the patient and his close relatives at the time of transfer or discharge.

24. Pupillary Changes in head injury
patients

25. Clinical signs in head injury
patients

26. Extradural Hematoma

27. Subdural Hematoma

28. Intracerebral Hematoma

29. Skull fractures

30. Thank You