MANAGEMENT OF HEAD

INJURIES AND
PREVENTION OF
SECONDARY BRAIN
DAMAGE
DR KASTURI VISVALINGAM
DR ABDUL RASHID BIN
ABDUL GHANI
INTRODUCTION
Management of traumatic brain injury focuses on stabilisation of the patient and
prevention of secondary neuronal injury to avoid further loss of neurons.
Full neuromonitoring including intracranial pressure measurement are rarely
available prior to the patients arrival in the intensive care unit.
Significant neurological damage can occur between the time of injury and CT
scanning, accurate measurement of ICP and other parameters.
The acute management of these patients is therefore directed towards assuming
there is significant intracranial pathology and instituting measures to protect living
brain tissue.
PATHOPHYSIOLOGICAL
DISTURBANCE
Head injury can involve the scalp, cranium and/or underlying brain.
Scalp injuries include lacerations, contusions and abrasions, depending on the
mechanism of injury.
Fractures of the skull can involve the vault or base, be simple or compound,
depressed or planar. Brain injury can result from the original impact (primary), or
can result from the development of secondary complications.
Primary brain injury can be focal (i.e. intra-cranial haematoma, contusion), and/or
diffuse (diffuse axonal injury).
Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing
disruption and tearing of axons.
Intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may
occur adjacent to (coup) or contralateral (contre-coup) to the side of impact.
Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial
herniation exacerbates the original injury.
The normal autoregulation of cerebral blood flow is lost in a head injury making an injured brain
more susceptible to hypo- or hypervolaemia and hypoxia.
The classical Cushings Reflex is a late event, and often immediately pre-mortem.
(physiological nervous system response to increased ICP that results in Cushings Triad:
a) Increased BP
b) Irregular breathing
c) Reduction of heart rate
- Seen in terminal stages of acute head injury and may indicate imminent brain herniation.

CLINICAL ASSESSMENT
Assessment of the head-injured patient begins with the Advanced Trauma Life
Support (ATLS) protocol of ensuring patency of the airway with cervical spine
control whilst maintaining good oxygenation and tissue perfusion.
This aims to prevent the development of secondary brain injury. Of vital
importance is the need to treat the casualty as if there is an unstable cervical spine
injury before attempting endotracheal intubation, if required.
Between 5 and 10% of head injuries have an associated cervical spine injury.
Such an injury can be excluded in almost all cases with a combination of
computerised tomography (CT), magnetic resonance imaging (MRI) or flexion-
extension radiography of the neck, should clinical suspicion indicate it.
Once the clinician is satisfied that the patient is resuscitated with a stable
cardiorespiratory status, neurological assessment can occur. Neurological
examination begins with assessment of the patients conscious level using the
GCS.
The severity of the head injury can be based on this initial GCS score. A patient
with a GCS of 8 or less is in need of urgent anaesthetic assessment as airway
compromise and/or reduced lung ventilation is likely.
Pupil size and reaction to light are also assessed. Asymmetrical pupil size and
reduced reaction to light may indicate brain injury from either diffuse injury or an
intra-cranial heamatoma.
It may also, however, indicate an isolated injury to the orbit and associated cranial
nerves.
Asymmetry of limb movement may help in diagnosing an underlying intra-cranial
lesion.
Observations on the blood pressure, pulse and respiratory rate are also essential,
not only to ensure cardiorespiratory stability of the patient, but also to indicate
possible brainstem compromise.
The mechanism and time of injury, delay in treatment, previous medical history of
the patient (e.g. epilepsy, diabetes mellitus) and the presence of alcohol and other
drugs that may effect the conscious level are important to ascertain.
Exposure of the patient to examine for any other injuries is then made, including a
thorough inspection of the patients scalp for lacerations, compound fractures and
contusions.
INVESTIGATIONS
All patients with multiple injuries and those with severe head injuries, should have blood
samples analysed for baseline estimations:
full blood count (FBC)
electrolytes and urea (RP)
coagulation screen (PT/APTT/INR)
blood gases (ABG)
blood group (GSH/GXM)
Electrolyte abnormalities and haemoglobin deficiencies should be corrected, if present,
whilst clotting disorders should be corrected if surgery is anticipated.
With the greater availability of CT, more head-injured patients are being scanned.
Skull radiography can be used in the absence of CT scans.
But it is by no means comparable as those with head injuries and skull fractures should be
considered to have intracranial pathology until proven otherwise.
MANAGEMENT
The ATLS management of head-injured patients depends on the GCS following
resuscitation.
Patients with a mild head injury (GCS 14-15) should be admitted to a ward where thorough
and frequent neurological observations can be ensured.
Should such a patient subsequently deteriorate neurologically (e.g. deteriorating GCS or
increasing focal neurological deficit) a CT scan of the patients head should be performed
promptly, and the local neuro-surgical unit contacted.
Patients with a mild head injury should be observed until they make a complete
neurological recovery and are only discharged if a responsible adult can supervise them at
home for a further few days.
All patients with a GCS of 13 or less should receive a CT scan of their head although many
authorities would advocate a CT scan on all whose GCS is not normal.
Those with an acute lesion on CT scan or evidence of diffuse cerebral oedema should be
urgently discussed with the local neurosurgical unit, with the CT images transferred
immediately, either by computer image-link or courier..
All CT scans should be accompanied by a provisional radiology report from the
referring hospital.
Other indications for neurosurgical referral include:
a) compound depressed skull fracture
b) severely depressed fracture
c) deteriorating GCS score even with a normal scan
d) cerebrospinal fluid otorrhoea and rhinorrhoea
The following details are necessary when making a neurosurgical referral:
Name
Age
Sex
Date, time and mechanism of injury
Initial GCS on scene (documented by paramedics)
GCS following resuscitation (before administration of anaesthetic agents should they be required)
Evidence of deteriorating GCS
Pupil reaction
Vital observations
Previous medical and drug history
Previous functional ability and mobility in the case of elderly patients,
Other injuries and management of the patient since injury
TRANSFERRING PATIENT TO A
NEUROSURGICAL UNIT
Transfer of the head-injured patient should be carried out as expeditiously as possible.
A patient accepted for transfer to a neurosurgical unit should be accompanied by an
Medical Officer or a House officer, even if not intubated, as neurological deterioration and
airway compromise together with hypoventilation may occur in transit.
Furthermore, the physical disturbance caused by an ambulance journey and the
movement into and out of the ambulance can adversely affect cardiovascular stability in a
seriously injured patient.
Consequently, it is vitally important to ensure the patient is stable before transfer and
monitored appropriately during the transfer. (Vital Signs).
A bolus dose of 200mg of intravenous Mannitol (20% solution) over 20 mins may be given
to severely head-injured patients to reduce associated cerebral oedema.
It can buy time during transfer of a patient with clear signs clinically or on CT, of an
expanding intracranial haematoma.
Any seizures should be treated with 100mg of phenytoin administered intravenously TDS.
INDICATION FOR SURGERY
The decision to operate on a head-injured patient is based on a number of factors
including premorbid state, the severity of initial injury, the onset and rapidity of neurological
deterioration and patient assessment on arrival at the centre.
Important radiological features on CT scan include size of focal lesion(s) together with any
associated surrounding oedema and midline shift.
Also to be considered, in particular in the case of elderly dependant patients, are the
wishes of the relatives.
Before embarking on a neurosurgical procedure, it is important to correct any clotting
deficiencies and order the required amount of cross-matched blood.
With the aid of the CT scans, the operation is then planned in consultation with the
consultant neurosurgeon-on-call, and the appropriate theatre staff informed. In exceptional
circumstances, neurosurgical intervention, in the form of exploratory burr holes, may be
made at the tertiary centre or the referring hospital.
CONCLUSION
Modern management of head injuries at the neurosurgical unit involves
continued ventilation, surgery, intensive care unit management of intra-
cranial pressure and cerebral perfusion pressure, oxygenation.
The aim of all of the above is to minimise any potential for secondary injury
and to present the neurosurgeon with a patient who is alive and has a good
chance of good quality survival.
CASE PRESENTATION
18 YEARS OLD BOY WITH NO KNOWN MEDICAL ILLNES
ALLEDGED MVA ( MB SKIDDED )
PATIENT WAS MOTORBIKE RIDER NOT WEARING HELMET
UNSURE MECHANISM OF INJURY
+LOC,+RETROGRADE AMNESIA, NO ENT BLEED ,BUT REGAINED
CONCIOUSNESS ON THE WAY TO HOSPITAL
LEFT SIDED HEADACHE AND SWELLING
LEFT SHOULDER PAIN WITH LIMITED ROM
NO VOMITING NO BLURRING OF VISION

ON EXAMINATION
GCS 15/15, PUPIL 3/3 REACTIVE
,NOT TACHYPNIC
VITAL STABLE, NO HYPOTENSIVE EPISODE
LUNGS CLEAR,EQUAL AIR ENTRY
CVS DRNM
P/A:SOFT NON TENDER, NO GUARDING

HEAD EXAMINATION NOTED THERE IS SCALP SWELLING OVER LEFT
FRONTO-TEMPORO-PARIETAL
FAST SCAN-NO FREE FLUID
CHEST X-RAY: NO PNEUMOTHORAX, NO RIB FRACTURE
CT BRAIN DONE:
-ACUTE EXTRA DURAL BLEED IN LEFT FRONTAL REGION(6X3X4 CM)
-ACUTE SUBDURAL BLEED RIGHT FRONTO-PARIETAL-TEMPORO-
OCCIPITAL LOBE( MAXIMUM THICKNESS IS 0.8CM)
-ACUTE BLEED IN INTERHEMISPHERIC FISSURE AND BILATERAL
TENTORIUM CEREBELLI
-LEFT LATERAL VENTRICLES IS COMPRESSED
-EXTENSIVE HEMATOMA OF LEFT FRONTO-PARIETO TEMPORO-
OCCIPITAL.



EMERGENCY CRANIOTOMY DONE
POST OP PATIENT SENT TO ICU FOR CEREBRAL PROTECTION AND
CONTINUATION OF CARE
CT BRAIN REPEATED THE NEXT DAY.

REPEATED CT BRAIN
-RESOLVING LEFT FRONTAL EXTRADURAL BLEED

AFTER COMPLETED CEREBRAL PROTECTION,PATIENT WAS
EXTUBATED AND SENT TO GENERAL WARD
PATIENT PROGRESS IS WELL, AMBULATING AND TOLERATING
ORALLY WELL
NO FEVER, NO HEADACHE , BLURRING OF VISION.
DISCHARGED WELL.
THANK YOU