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Approach to a case of HEAD INJURY in RTA 20th CME Genpact Medical Team

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Approach to a case of HEAD INJURY in RTA 20th CME Genpact Medical Team Presented By: Dr.(Maj) Natasha Singh Gurgaon 4th Jun 2008 Epidemiology Accidents on Indian Road ... – PowerPoint PPT presentation

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Title: Approach to a case of HEAD INJURY in RTA 20th CME Genpact Medical Team


1
Approach to a case of HEAD INJURY in RTA20th
CME Genpact Medical Team
  • Presented By
  • Dr.(Maj) Natasha Singh
  • Gurgaon
  • 4th Jun 2008

2
Epidemiology
  • Accidents on Indian Road 
  • Accidents are quite common on Indian Roads.
    Currently motor vehicle accidents rank ninth in
    order of disease burden and are projected to be
    ranked third in the year 2020. Worldwide, the
    number of people killed in road traffic crashes
    each year is estimated at almost 1.2 million,
    while the number injured could be as high as 50
    million. In India, over 80,000 persons die in the
    traffic crashes annually, over 1.2 million are
    injured seriously and about 300000 disabled
    permanently.

3
INDIAN STATISTICS
  • Every minute there is an accident
  • Every 8th minute there is death due to RTA
  • There are 6 lac RTA / year and 1 lac deaths /
    year which is 21/2 times higher than USA / 1000
    vehicles and the mortality related to RTA in
    India is 10 times higher than USA. The reason
    being
  • 1) improper resuscitation
  • 2) delay in transportation of the case to a
    tertiary care center
  • In respect to the no. of Kms of road, RTA is 960
    times as compared to US
  • In RTA, 70 deaths are due to Head Injury and
    majority of deaths occur with in 72 hrs.
  • Head Injury due to RTA is most frequent in 20
    40 yrs of age goup.

4
Reasons for high accident rate in India
  • ROADS Poor design, lack of safety measures,
    poor lighting, lack of maintenance
  • VEHICLES Poor std, lack of proper break system
    and seat belt, non-motorised vehicles( cycle
    rickshaws etc..)
  • DRIVING DVRS Inadequate training, easy
    availability of license, not following traffic
    rules, poor visual acquity, alcohol/drugs

5
  • DEFINITION
  • Head injury is a cranio-cerebral injury,
    which means the involvement of brain is present
    and hence there has to be some duration of
  • 1) LOC
  • 2) PTA
  • 3) Seizures after the injury
  • Head injury can be defined as any alteration in
    mental or physical functioning related to a blow
    to the head. Loss of consciousness does not need
    to occur.

6
Severity of Head Injury
  • The severity of head injuries most commonly is
    classified by the initial post resuscitation
    Glasgow Coma Scale (GCS) score, which generates a
    numerical summed score for eye, motor, and verbal
    abilities. A score of 13-15 indicates mild
    injury, a score of 9-12 indicates moderate
    injury, and a score of 8 or less indicates severe
    injury.
  • The severity of head injury is also proportional
    to the period of LOC
  • Mild less than 30 min GCS 13-15
  • Moderate 30 min to 6 hrs GCS 9 - 12
  • Severe more than 6 hrs GSC 8 or less

7
Glasgow Coma Score The GCS is scored between 3
and 15, 3 being the worst, and 15 the best. It is
composed of three parameters Best Eye Response,
Best Verbal Response, Best Motor Response, as
given below
  • Best Eye Response. (4)
  • No eye opening.
  • Eye opening to pain.
  • Eye opening to verbal command.
  • Eyes open spontaneously.
  • Best Verbal Response. (5)
  • No verbal response
  • Incomprehensible sounds.
  • Inappropriate words.
  • Confused
  • Orientated

8
  • Best Motor Response. (6)
  • No motor response.
  • Extension to pain.
  • Flexion to pain.
  • Withdrawal from pain.
  • Localizing pain.
  • Obeys Commands.
  • Max GCS 15/15 Min GCS 3/15
  • GCS is never 0.
  • A Coma Score of 13 or higher correlates with
    a mild brain injury, 9 to 12 is a moderate injury
    and 8 or less a severe brain injury.

9
Pathophysiology
  • Both direct impact and countercoup injuries,
    in which the moving brain careens onto the
    distant skull opposite the point of impact, can
    result in focal bleeding beneath the calvaria.
    Such bleeding can result in an intracerebral
    focal contusion or hemorrhage as well as an
    extracerebral hemorrhage. Extracerebral
    hemorrhages are primarily subdural hemorrhages
    arising from tearing of bridging veins, but
    epidural hemorrhages from tearing of the middle
    meningeal artery or the diploic veins are also
    common.

10
Intracranial Volume
  • Total Volume is around 1500ml, out of which 80
    is brain matter, CSF in ventricles is 40ml,
    subarachnoid and in cisterns is 50 70 ml. CBV
    (cerebral blood volume) is approx. 150ml
  • Normal ICP 0-15 mmHg
  • Abnormal ICP gt 20 mmHg, pressure more than
    this increases the likelihood of LOC

11
  • History
  • History in most patients with head injury should
    be self-evident.
  • The patient may be comatose or confused, and
    witnesses to the accident or injury are of
    obvious and crucial importance.
  • Elicit the time, type and mechanisms (mode) of
    the injury, as these may have prognostic value.
    Patients sustaining a head injury from an assault
    or from being struck with a falling object have a
    markedly greater likelihood of poorer vocational
    outcomes than patients sustaining the more common
    acceleration/deceleration injuries, presumably
    because the former injury types entail greater
    axonal damage.
  • Ascertain whether the patient lost consciousness.
    Even a questionable loss of consciousness can be
    a marker of severe neurological injury.
  • Alcohol use may raise the risk of intracranial
    bleeding and cloud the mental status assessment.
  • Present anticoagulant therapy is also worrisome.
  • Carefully consider past psychiatric disease and a
    premorbid history of headaches.

12
  • Signs of serious injury include
  • Drowsiness or confusion
  • Nausea or vomiting
  • Severe headaches
  • Fits
  • Leakage of cerebrospinal fluid from the ear or
    nose
  • Weakness or loss of sensation in the limbs
  • Asymmetry of the pupils and double vision
  • In such individuals a more thorough
    evaluation and closer observation is necessary
    and further investigations need to be carried
    out.
  • Symptoms
  • After a concussion one may suffer from a
    post-concussive syndrome and may experience one
    or more of the following symptoms
  • Headache
  • Irritability
  • Anxiety
  • Difficulty with memory
  • Impaired concentration and attention span
  • Lethargy
  • Personality changes
  • Insomnia, dizziness
  • Ringing in the ears
  • Blurring of vision
  • Decreased taste and smell

13
  • Elementary neurologic examination
  •           
  • The GCS is the mainstay for rapid neurologic
    assessment in acute head injury. Both initial and
    worst GCS scores have correlated significantly
    with 1-year outcomes following severe head
    injury.
  • Following ascertainment of the GCS score, focus
    the examination on signs of external trauma.
    Bruising or bleeding on the head and scalp and
    blood in the ear canal or behind the tympanic
    membranes may be clues to occult brain injuries.
    Also consider coexistent cervical spine and other
    systemic injuries.
  • Anosmia is common and probably is caused by the
    shearing of the olfactory nerves at the
    cribriform plate. If accompanied by rhinorrhea, a
    CSF leak with the attendant risk of ascending
    meningitis must be excluded.
  • Abnormal pupillary reactivity correlates with a
    poor 1-year outcome. A unilaterally dilated pupil
    with or without ipsilateral cranial nerve (CN)
    III paralysis may indicate impending herniation.
  • CN VI palsies may indicate raised intracranial
    pressure. CN VII palsy, particularly in
    association with decreased hearing, may indicate
    a fracture of the temporal bone.

14
Indications of CT Scan
  • GCS less than 13 at any time, or 13 -14 at 2hrs
    after injury
  • Suspected skull fracture or penetrating head
    injury
  • Post-traumatic epileptic seizure
  • Focal neurological deficit
  • Vomitting
  • Retrograde amnesia for more than 30 mins
  • Any loss of consciousness or amnesia if also
  • age gt 65 yrs
  • coagulopathy
  • high impact head injury

15
Classification
Head Injury
Extra-Dural Haemorrhage
Sub-Dural Haemorrhage
Intracerebral Haemorrhage
16
A CT brain scan showing depressed skull fractures
over the frontal area
  • Symptoms
  • A simple or mildly depressed skull fracture may
    only present with pain and swelling over the area
    concerned.
  • In depressed skull fractures, there is often
    pressure on the brain or direct injury to the
    brain. The depressed bone fragment may also
    result in a tear or the dura mater, and cause a
    cerebrospinal fluid leak.
  • For skull base fractures, the following
    symptoms may occur
  • Cerebrospinal fluid leakage.
  • Blood behind the eardrum.
  • Bruising behind the ears ( battles sign) or
    around the eyes (panda eyes) .
  • Nerve damage, causing weakness of the face.
  • Loss of hearing, smell or vision or double
    vision.

17
A CT brain scan showing the area of hyperdensity
that is thicker than the skull vault thickness in
EDH
  • The typical symptom that occurs in EDH is a
    transient loss of consciousness followed by a
    period of awareness that may last several hours
    before decreasing consciousness occurs again
    (LUCID INTERVAL). At this point further
    deterioration leading to a coma and even death is
    possible
  • After the injury, the patient is momentarily
    dazed, and then becomes relatively lucid for a
    period of time which can last minutes or hours.
    Thereafter there is rapid decline as the blood
    collects within the skull, causing a rise in
    intracranial pressure, which damages brain
    tissue.
  • Lucid interval is seen in around 18 of classical
    EDH cases

18
A CT brain scan showing the crescent shaped area
of blood clot and pressure from the clot causing
shift of the brain structures to the opposite
side in Acute Sub Dural Haemorrhage
  • Patients with a small acute SDH may remain
    conscious and just suffer from symptoms related
    to a concussion or contusion. If the SDH
    progressively enlarges, there will be a further
    deterioration of conscious level.
  • In contrast to EDH, the time between trauma and
    the onset of symptoms is typically longer in SDH.

19
A CT brain scan showing a large blood clot with
surrounding pressure and swelling of the brain
structures in Intracerebral hemorrhage (ICH)
  • Symptoms usually involve sudden onset of
    stroke like symptoms such as
  • Numbness of the face, arm or leg on one side of
    the body
  • Weakness of the face, arm or leg on one side of
    the body
  • Sudden and severe headache with no apparent cause
  • Difficulty speaking or understanding language
  • Dizziness, loss of balance, or loss in
    coordination
  • Visual loss
  • Other symptoms include sudden onset of headache,
    seizures or loss of consciousness

20
Acute management
  • In the setting of acute head injury, give
    priority to the immediate assessment and
    stabilization of the airway and circulation
  • At the site of Accident
  • Care of airway
  • Oxygenation
  • BP Pulse monitoring
  • IV access
  • Scoop stretcher
  • Transportation Golden Hr 1st Hr of injury

21
Acute management Contd
  • In the medical room
  • Quick examination
  • Air way
  • Ventilation
  • Circulation BP, Pulse, CVP
  • Hypotension IVF
  • Arrest Bleeding
  • Always look for cervical spine injury in case of
    Head trauma
  • Look for any injury in Chest, Abdomen, Limbs etc
  • After stabilization transport the case to
    Hospital setup for investigation further
    management

22
Acute management Contd
  • In Hospital Setup
  • Following stabilization, direct attention to
    prevention of secondary injury.
  • Next, focus attention on reducing intracranial
    pressure, since elevated intracranial pressure is
    an independent predictor of poor outcome. If the
    intracranial pressure rises above 20-25 mm Hg,
    intravenous mannitol, CSF drainage, and
    hyperventilation can be used.
  • Phenytoin has demonstrated efficacy in
    controlling early posttraumatic seizures,
  • Neuroprotective agents like, the calcium channel
    blocker Nimodipine can help in reducing rates of
    death and severe disability when instituted
    acutely in patients with head injuries and
    traumatic subarachnoid hemorrhages

23
Consultations
  • In the acute setting, a consultation with a
    neurosurgeon is critical for patients with
    moderate or severe head injuries, focal
    neurological findings, or intracranial pathology
    identified on neuroimaging.
  • Medications commonly are used in the acute
    setting to control early seizures, reduce
    intracranial pressure, and correct electrolyte
    abnormalities. Nimodipine may be neuroprotective
    in the subset of patients with traumatic
    subarachnoid hemorrhages.

24
The patient (Head Injury) first seen in medical
room
Mild Moderate
Moderate - Severe
Mild
Stabilize the case and transfer to hospital setup
Observe in Medical room
Unstable
Stable
CT Scan and Neurosurgical care
Home
25
Progression of events in case of Head Injury
Compression
Injury
Hematoma
Pushes temporal lobe medially giving rise to
irritation/compression of III cranial nerve
Compression of Crus Cerebrii (in mid brain)
leads to Contralateral Hemiparesis
Very brief constriction followed by gradual
dilatation of Ipsilateral pupil
Further compression
Further compression
LOC / COMA
Bilateral dilatation of Puplis
Herniation of brain stem Into foramen magnum
Brain Death
Depression of cardio respiratory center
26
Complications
  • Mild head injuries are those that generate GCS
    scores of 13-15. Such injuries usually are
    considered relatively benign, and the
    accompanying cognitive impairments typically
    resolve within 3 months of injury.
  • However, an initial grading of "mild" does not
    necessarily mean a mild outcome. As many as 3 of
    patients with an initial mild injury may require
    a neurosurgical operation. Some patients have
    died hours after sustaining trivial head
    injuries.
  • Posttraumatic seizures occur clinically in
    approximately 4 of patients with head injuries
    within the first week of the head injury.
    Seizures after the first week occur in 4-30 of
    patients
  • Posttraumatic headaches are common and may occur
    in 30-80 of patients after a head injury.
    Posttraumatic headaches typically manifest with a
    vascular component, but chronic daily headaches
    are also common

27
Complications Contd
  • Posttraumatic movement disorders like tremor,
    dystonia, parkinsonism, myoclonus, and
    hemiballism all can occur following head
    injuries.
  • Posttraumatic psychiatric disorders- Disorders of
    emotional functioning have been documented
    repeatedly after head injuries.
  • Other complications can be, CSF leak,
    hydrocephalus, meningitis, brain abscess
  • Chronic SDH can occur after 4-6 weeks, which is
    common in old people

28
Prognosis
  • The most important prognostic factors are
    probably age, mechanism of injury,
    postresuscitation GCS score, postresuscitation
    pupillary reactivity, postresuscitation blood
    pressures, intracranial pressures, duration of
    posttraumatic amnesia or confusion, sitting
    balance, and intracranial pathology identified on
    neuroimaging.
  • The mortality rate of severe head injuries ranges
    from 25-36 in adults within the first 6 months
    after injury. Most deaths occur within the first
    2 weeks.

29
Medical/Legal Pitfalls
  • Head injuries and their sequelae are embedded
    inextricably in the medicolegal system. Both
    malpractice suits and tort litigation arise from
    the acute and long-term care of patients with
    head injuries.
  • A detailed history, review of systems, and
    complete examination is therefore essential.
  • Incorporate previous head injury, head pain,
    psychiatric treatments, and medication failures
    in the medical history.
  • Documentation should be meticulous.The physician
    must substantiate that a certain event likely
    induced a brain injury delineate the physical,
    emotional, and cognitive consequences of that
    injury and arrive at a prognosis for recovery
  • Finally, patients with pain and emotional
    complaints that are refractory to standard
    management must receive documented referrals to
    appropriate specialists.

30
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