Head Injury

• Scalp injury
• Skull injury
• Meningeal injury
• Traumatic Brain Injury
 WHAT
IS THE DEFINITION OF A
TRAUMATIC BRAIN INJURY
(TBI)?
an acquired injury to the brain caused
by an external physical force resulting
in total or partial functional disability or
psychosocial impairment or both.
Stroke
Brain Infection
Tumor
Anoxia
Exposure to Toxic Substances
 Important note:

Brain injuries
that result from either an
external
or internal force
may have similar effects.
 Epidemic in Indonesia
 Major cause of death and permanent
disability
 70% of all road fatalities
 50% of trauma death
 10-20% of head injury: death on arrival
 Degree : 70% mild head injury
15% moderate head injury
15% severe head injury
 Severity of primary injury
 Intracranial complications
 Hypotension
 Anaemia
 Multiple injuries
 Age
 Prolonged prehospital time
 Delayed interhospital transfer
1. Headache
2. Vomiting
3. Papilloedema
4. Cushing response
› Bradicardia
› Hipertension
› Alteration of ventilatory pattern
 Mild – GCS 14-15
Patient typically mildly lethargic, disoriented
 Moderate – GCS 9-13
Patient typically sleepy or obtunded, able to
follow commands with arousal.
Confused.
 Severe – GCS 3-8
Patient comatose, unable to follow command or
perform purposeful motor activity.
Severity GCS LOC PTA
Mild 14–15 <20 min-1 hr <24 hr
Moderate 9–13 1 – 24 hrs. > 24 hrs.
- <7days
Severe 3–8 >24 hrs. >7 days

GCS = Glasgow Coma Scale

LOC = Loss of consciousness
PTA = Posttraumatic amnesia
 Gambar COB dgn ETT
Early management of severe trauma
The management plan is based on:
1. Primary survey
2. Resuscitation
3. Secondary survey
4. Definitive care
Glasgow Coma Scale (GCS)
This scale examines three areas of behaviour: eye
opening, response to voice and motor responses. The
score can be quantitative with 3 being the lowest
score and 15 normal
 Eye opening
› Spontaneous E4
› To speech 3
› To pain 2
› Nil 1
 Verbal response
› Orientated V5
› Confused conversation 4
› Inappropriate words 3
› Incomprehensible sound 2
› Nil 1
 Best motor response
› Obeys M6
› Localizes 5
› Withdraws 4
› Abnormal flexion 3
› Extension 2
› Nil 1
 Coma Score (E+V+M) = 3-15
 CT head scan guidelines
› GCS < 15 after resuscitation
› Drowsiness or confusion (GCS 9-14
persisting>2 h)
› Persistent headache, vomiting
› Focal neurological signs
› Fracture – known or suspected
› Penetrating injury – known or suspected
› Age – over 50 years of age
 Skull X-ray guidelines
In rural area where a CT scan is not available
or readily accessible, a plan skull X-ray can
provide useful information.
 Indications
› Loss of consciousness, amnesia
› Persisting headache
› Focal neurological signs
› Scalp injury
› Suspected penetrating injury
› CSF or blood from nose or ear
› Palpable or visible skull deformity
 Epidural Hematoma – EDH
› Lens shaped hematoma between dura and
skull
› Associated with skull fracture and laceration of
dural artery (e.g. Middle meningeal artery)
› Urderlying brain is ussually not injured
› Often present with brief loss consciousness,
followed by lucid interval of minute to hours,
before rapid neurological decline into coma
› Extreme neurosurgical emergency. Timely
diagnosis and surgery is often followed by
excellent recovery
 Subdural hematoma – SDH
› Crescent shaped hematoma lying between
brain and dura, conforming to brain surface

› Indicative of high acceleration /

deceleration injury with tearing of bridging
veins or cortical arterioles

› Extreme neurosurgical emergency

› 30% mortality, 70% good outcome

THANK YOU
 Primary survey
› Airway with cervical spine immobilized in
neutral position
› Breathing pattern and adequacy
› Circulation and haemorrhage
› Disability, minineurological examination:
 GCS
 Pupils
 Motor deficit
› Exposure: completely expose the patient for
an adequate examination but protect
against hypothermia
 Resuscitation
› Airway
 Ensure patient airway
 Unconscious patient: intubated if skilled
 Note: maintain cervical spine immobilization
until radiological examination excludes spinal
injury
› Breathing and oxygenation
 Ensure adequate ventilation
 Mechanically ventilate if intubated
 Give supplemental oxygen initially
› Circulation support and control
haemorrhage
 Treat shock aggressively to improve
tissue perfusion
 Control external haemorrhage
› Assess response to resuscitation using
physiological parameters: pulse, blood
pressure, skin colour, capilary refill and
urine output
› Nasogastric tube and urinary catheter
unless contraindicated
 Secondary survey
› Special neurosurgical assessment including
Glasgow Coma Score (GCS) and external
sign of injury to the head
› Record the pulse, blood pressure, respiratory
rate and temperature
› Systematically examine each region of the
body, i.e. head-to-toe examination
› Connect to monitors as available
› Re-evaluate the GCS
› Radiological examination-lateral X-ray spine,
chest, pelvis, other areas as indicated, skull
X-ray and CT head scan