CME:

Head Injury
 Table of contents

01 02
Approach to head Primary and
injury secondary survey

03 04

Interpretation of Treatment and

CT brain management
 Approach to
01 head injury
 Introduction to the head injury

Definition
Blunt/penetrating injury to
the head and/or brain due to
external force with temporary
or permanent impairment in
brain function which may or
may not result in underlying
structural changes in the
 Causes of head injury

1. Falls - especially in the young children

and
geriatric population
2. MVAs
3. Physical assaults
4. Sports injuries
5. Blast/combat injuries
One or more of the following conditions from anatomical and
physiological changes must be present with head injury

Physiological changes
• Observed or self-reported loss of or
decreased level of consciousness
• Any loss of memory of events immediately
before or after the injury
• Any alteration in mental state or
neuropsychological abnormality at the time
of injury
• Objective neurological deficits (such as
weakness, loss of balance, change in vision,
praxis, paresis/paraplegia, sensory loss and
aphasia) that may or may not be transient.
 Anatomical changes

• Scalp and/or facial wound or swelling

• Skull fracture (facial, basilar or vault)
an/or Clinical signs of skull fracture
• Diagnosed intracranial lesion such as
brain parenchyma injury, injury to
intracranial blood vessels, injury to dura
mater, intracranial haemorrhage,
subarachnoid haemorrhage or
intraventricular haemorrhage
Classification of head injury
Primary brain Secondary brain
injury injury

Induced by Not mechanically

mechanical induced. It may
forces and occurs at superimpose injury
the time of injury on
brain already
affected
by mechanical injury
 Classification of head injury
Open injury Closed / non
penetrating injury

• Injury to the brain

• Occurs when
without breaking
there is a break in
the skull.
the skull
• Caused by a rapid
• Eg : impact of a
forward or
bullet, knife or
backward
sharp objects
movement and
shaking of the brain
inside the bony
skull that results in
bruising and tearing
 Classification of head injury
Diffuse brain
Focal brain injury injury

• Due to contact and • Due to acceleration-

causing scalp injury deceleration injury
• May represents as and concussion
skull fracture, resulting in diffuse
contusions or axonal injury and
intracranial brain swelling
haemorrhage
Classification of head injury
Types of Focal Head Injury
Clinical Manifestations
of Brain Injury
- Disturbances in consciousness
- Confusion to coma
- Headache/ dizziness/ Vertigo
- Disorientation/ Agitation/ Restlessness
- Nausea and vomiting
- Pupillary abnormalities
- Respiratory changes
- Vital sign changes - tachycardia, tachypnea
- Altered/ absent cough/ gag reflex
- Sensory, visual and hearing impairment
- Hemiparesis/ hemiplagia
- Impaired mental function
- Ataxia
Battle sign (bruises over
mastoid region)
 Raccoon eye (periorbital
ecchymosis) with
subconjunctival heamorrhage
Glasgow Coma Scale (GCS)

* can be
influenced by
alcohol
intoxication,
sedative
medications,
hypoxia and
hypotension
 Severity of brain injury
Mild Moderate Severe
GCS 13-15 9-12 ≤8
Duration of >30 mins
> 24
unconsciousne <30 mins and <24
hours
ss hours

Post traumatic >1 and <7

<1 day > 7days
amnesia days

Normal
Structural Normal or or
Normal
imaging abnormal abnorm
al
Classification of mild head injury
Diagnosis/ Investigations
- Complete and detailed history colletion and
thorough physical examination
- Bloods: FBC, Coagulation profile
- CT scan + repeated head CT + cervical imaging

- X- Ray (skull)
- MRI
- Electroencephalography (EEG)
- Positron emission tomography
 Differential Diagnoses
• Primary anoxic, inflammatory, infectious, toxic or metabolic
encephalopathies, which are not complications of head
trauma
• Neoplasms
• Brain infarction (ischaemic stoke) and intracranial
haemorrhage (haemorrhagic stroke) without associated
trauma
• Alcohol intoxication, psychotropic drugs or substance
abuse
• Seizure
 Special Considerations
• Anticoagulants should be immediately stopped and reversed
in patients with intracranial bleeding by using Vitamin K
(only for patients on Warfarin), fresh frozen plasma,
prothrombin complex concentrate or recombinant factor VIIa
as indicated and there should be consultation on this matter
among relevant specialists
• There is insufficient evidence on when to restrat antiplatelet
and anticoagulant in patients with head injury
• If there is urgent need for anticoagulant but risk of bleeding
is still considered as reasonably high, decision on when and
how to start anticoagulant should be decided by a
multidisciplinary team
 Primary survey
02 and secondary
survey
PRIMARY SURVEY
 Primary survey
ABCDE :
A - Airway
B - Breathing
C - Virculation
D - Disability
E - Exposure
 Airway Assessment with
Cervical Spine Control

● Ascertain pathway
○ (1) Foreign Bodies, (2) Facial/Mandibular #, (3) Laryngeal/Tracheal #
● Assess for airway obstruction
○ Engage the patient in conversation – a patient who cannot respond verbally
is
○ (1) stridor, (2) retractions, (3) cyanosis
● Establish a patient airway
○ Jaw Thrust – displace tongue anteriorly from the pharyngeal inlet relieving
obstruction
○ Simple Suctioning / Clear Airway of Foreign Bodies
○ Nasopharyngeal airway / Oropharyngeal Airway
 Tracheal Intubation

● Orotracheal route using rapid-sequence induction (RSI)

● Pre-oxygenate patient with 100% Oxygen
● In-line cervical spine stabilisation wither anterior portion of cervical collar removed
● Sellick Manoeuvre -to prevent aspiration there is increasing controversy as to the utility
of cricoid pressure due to concerns about its efficacy and potential for obscuring the
view of the vocal cords)
● Drugs – short acting sedative or hypnotic agent (i.e. etomidate 0.3mg/kg IV or
midazolam 1-2.5mg IV) and paralytic agent administered immediately after the
sedative (succinylcholine 1-1.25mg/kg IV or rocuronium 0.6-0.85mg/kg IV)
● ETT tube inserted through vocal cords and adequacy of ventilation is assessed
● Needle Cricothyroidotomy with jet insufflation of the airway
● Surgical Cricothyroidotomy
 IN LINE CERVICAL
IMMOBILIZATION
● Support the cervical column by palm resting on the shoulder
● Measurement: from angle of mandible to base of neck (how many
finger breadth)
● Check for fitting: at least 1 finger can fit in underneath
● NEXUS criteria (NSAID): if don’t have can remove cervical collar
○ N - Neurological deficit
○ S - Spinal tenderness
○ A - Altered sensorium (poor conscious level)
○ I - Intoxication
○ D - Distracting pain
● Check before remove the cervical collar: any pain during right & left
rotation of neck, if have DON’T REMOVE!
● Age > 65, children <10 y/o, neck problem (Rheumatoid arthritis, neck
surgery) CANT USE NEXUS CRITERIA

❏ Remove:
❏ Foreign body (use forceps)
❏ Salivation, blood, vomitus (Yankauer suction)

❏ At the same time look for gag reflex (no gag reflex brain stem injury from ponsà
poor prognosis

❏ If no reflex → put on adjunct airway (oropharyngeal airway)

❏ Measure the size of airway from pinna to angle of the mouth
❏ Then put ambu bag or if pt can maintain O2 saturation give high flow
mask
 Breathing

Assessment of breathing
● Expose the neck and chest: ensure immobilization of the head and neck
● Determine rate and depth of respiration
● Inspect and palpate the neck and chest for tracheal deviation, unilateral and
● bilateral chest movements, use of accessory muscles and any signs of injury (i.e. flail
● chest)
● Auscultate chest bilaterally: bases and apices
● If unequal breath sounds – percuss the chest for presence of dullness or hyper-
● resonance to determine hemothorax or pneumothorax
Life Threatening Conditions
 Circulation with Haemorrhage
Control
Hypotension following injury must be considered to be hypovolemic in origin until proven
otherwise
Assessment of organ perfusion

● Level of consciousness (secondary to reduced cerebral perfusion)

● Skin Colour (ashen and grey skin of face and white skin of extremities suggest blood
loss of at least 30%)
● Pulse Rate and Character (full vs. thread vs. rapid)
● Blood Pressure (if radial pulse present – BP>80mmHg, if only carotid pulse present –
● BP>60mmHg)
 Damage control
resuscitation:

1. Limit fluid (maximum 2 pint of NS)

2. Start early blood transfusion 1:1:1 ratio pack cell: FFP:
cryoprecipitate
○ Transfuse until pt improve clinically and shock class drop down
3. Early activation of massive transfusion protocol (MTP)
4. IV tranexamic acid 1g bolus
5. Aim for permissive hypotension
○ MAP: 85 mmHg
○ If head injury: aim systolic >90 mmHg (CP= MAP-ICP)
6. Bleeding control: search for wound/bleeding elsewhere: pelvic
binder
7. Damage control surgery: active call to surgery
 Disability / Intracranial Mass Lesion
● Alert
● Verbal stimuli (responds to),
● Pain stimuli,
● Unresponsive,
● Pupillary size and reaction

GLASGOW COMA SCALE (GCS)

 Exposure
● Completely undress patient by cutting off clothing
● Look for visible / palpable injuries
● Prevent hypothermia – “hot air” heating blankets, infusion of warmed IV fluids
● Inspection back / DRE – log-rolling with in-line cervical spine immobilization
● Continue monitoring vitals (HR, BP, SpO2) + ECG + urine o/p (aim: >0.5ml/kg/h
 Secondary Survey

A complete head to toe examination to inventory all injuries sustained in the trauma
after primary survey is completed
● AMPLE History (Allergies,medication,Past med,Last meal,Event/environment
related to injury)
● Complete head to toe examination
○ Respiratory System
○ Gastrointestinal System
○ Musculoskeletal system
○ Genitourinary System
 Interpretation
03 of CT brain
 INDICATIONS OF CT BRAIN

1. Altered mental status – sudden onset

2. TRO ICB secondary to acute head trauma
3. TRO CNS infection
4. TRO Elevated ICP
5. Hypertensive Emergency
6. Acute delirium
7. TRO Stroke
8. New Seizure
9. Worsening headache
10.Brain metastasis
INDICATION OF CT BRAIN
CANADIAN CT HEAD RULE
 PECARN PAEDIATRIC HEAD INJURY PREDICTION
RULE
Clinical decision aid that allows clinicians to safely
rule out the presence of clinically important
traumatic brain injuries, including those that
would require neurosurgical intervention among
paediatric head injury patients who meet its
criteria without the need for CT imaging

CT BRAIN INDICATION FOR PAEDS:

1. GCS 14 or less
• Child having agitation or somnolence
• Responding slowly to questions then usual
2. Palpable skull fracture/ deformity over head (eg:
hematoma)
3. LOC > 5 seconds
4. > 3 episodes of vomiting after injury
5. Seizure
PECARN
 HOUNSFIELD SCALE (HU)
◈ To measure how much of the X-ray
beam is absorbed by the tissues at
each point in the body. The denser
the tissue, the more the X-ray beam
is attenuated and the higher the
number
● Hyperdense - Higher density
than brain (Whiter appearance)
● Hypodense - Lower density than
brain (Darker appearance)
● Isodense - Same density as the
brain
PLANES OF CT HEAD

W 2000
L0
 STEPS IN INTERPRETATION CT BRAIN

a) Patient’s name & age

b) Date & time of scan
c) Previous scans (if available) for comparison
d) Study parameters - Anatomic region: Head &
Plane
e)
BLOOD CAN BE VERY BAD
CISTERN BRAIN VENTRICLE BONE
 BLOOD: TYPE OF INTRACRANIAL
HAEMORRHAGE
Acute haemorrhage appears hyperdense over the first few hours up to 7 days, then,
isodense over following 1-4 weeks & hypodense over subsequent 4-6 weeks

Extra-axial (Extracerebral)
◈ Extradural haematoma
◈ Subdural haematoma
◈ Subarachnoid hemorrhage

Intra-axial (Intracerebral)
◈ Intraparenchymal
haemorrhage
◈ Intraventricular haemorrhage
 Extradural haematoma
⮚ Extradural haematoma / epidural haematoma – collection of blood that forms between the
inner surface of the skull and outer layer of the dura, which is called the endosteal layer.
⮚ EDHs are usually limited in their extent by the cranial sutures
⮚ Usually does not cross suture lines where the dura tightly adheres to the adjacent skull.

EXTRADURAL HAEMATOMA
◈ Biconvex, lenticular shape
◈ Does not cross suture lines, midline
shifted
◈ Hyperdense, sharply demarcated
 Subdural haematoma
⮚ Subdural haematoma (SDH) - collection of blood accumulating in the subdural space, the
potential space between the dura and arachnoid mater of the meninges around the brain.

⮚ Bleeding beneath dura, following the shape of cerebral hemisphere, but restricted by falx
cerebri (does not cross midline)

SUBDURAL HAEMATOMA
◈ Crescentic shape along brain
surface
◈ Crosses suture lines
◈ Does not cross midline
◈ Hyperdense extra-axial
collection that spreads diffusely
over the affected hemisphere.
 Chronic subdural haematoma

● Commonly in elderly

● Usually 2-3 weeks after the initial trauma /

vigorous head movement (exercise)

● Hypodense crescent shape haematoma

 Subarachnoid haemorrhage
◈ Hyperdense lesions in the fissure
I. Traumatic
II. Spontaneous (suspect aneurysm!)
◈ May bleed into cistern
SUMMARY
 CEREBRAL CONTUSION
Cerebral contusion – ‘bruising’
of the brain
• Rupture of capillaries
(microhaemorrhage)

Mechanism:
• Sudden acceleration /
deceleration force will
result in the opposite
‘poles’ of the brain being
hit against the cranial vault

CT brain:
• Patchy hemorrhagic foci
mixed with low-density
oedema (salt-and-pepper
appearance)
• May need few hours to
show up in CT brain
 DIFFUSE AXONAL INJURY
Diffuse axonal injury (DAI) – injury to axons

Mechanism:
• Sudden acceleration & deceleration of head
• Brain rapidly shifts inside the skull as injury
is occurring
• Tearing of axons & myelin sheaths (in white
matter)

CT brain:
• May be normal, or petechiael haemorrhage
in grey-white junction, corpus callosum,
upper brainstem
 “CAN” : CISTERN
• Cisterns are collections of CSF, which
surround and protect the brain.
• Examine each for evidence of
effacement, asymmetry and the
presence of blood.

• Circum-mesencephalic —
surrounding the midbrain
• Suprasellar — around the circle
of Willis
• Quadrigeminal — located at the
top of the midbrain
• Sylvian — between temporal
and frontal lobes.
• Closure of the circummesencephalic cistern is one of the earliest signs
of increased intracranial pressure
• 80% of subarachnoid haemorrhages happen somewhere around the circle of
Willis / suprasellar cistern.

• One of the earliest places to see hydrocephalus is on the temporal tips of the
suprasellar cistern.
•Distal middle cerebral artery aneurysm (MCA)
• A SAH here may only fill up this cistern with blood.
•"Insular ribbon sign"
• The insular ribbon is the end organ of the middle cerebral artery - it is the
most distal brain perfused by the MCA.
• Loss of gray white matter here is the earliest sign of MCA ischemia.
 “BE”: BRAIN

Examine the Brain for:

◈Symmetry: Sulcal effacement
◈Grey-white matter
differentiation
◈Shift: Abnormal shifts of brain
tissue
◈Hypodense region - Air, fat,
ischaemia, tumour
◈Hyperdense region - Blood, IV
Symmetry: Sulcal Effacement

• Make sure sulci and gyri appear the same on both

sides.
• Check for effacement of sulci (unilateral or
bilateral).
Midline Shift

⮚ A connection line between the anterior-most point of

anterior falx and the posterior-most point of posterior falx
is formed.
⮚ Another parallel line passing through the septum
pellucidum is plotted (dotted line).
⮚ The midline shift can then be measured as the distance
between these two lines
(> 5
mm)
“VERY”: VENTRICLE

◈Intraventricular
haemorrhage (hyperdensity
within ventricular system)
◈Hydrocephalus
◈Ventricular effacement
 “BAD”: BONE Skull fracture

Linear fracture Depressed fracture

Open
Vault Basillar

Open Closed
◈ Look for evidence of
fractures Closed

Temporal Sphenoid Occipital Cranial

condylar fossa
Longitudinal (Type 1,2,3) (Anterior,
Posterior,
Transverse Middle)

Mixed
 Linear Skull Fracture
◈ Low-energy blunt trauma over a wide surface area of the
• - Runs through the entire thickness of the bone
skull.
• - It has little significance except when it runs
◈ Common type of fracture, especially in children younger through a vascular channel, venous sinus groove,
than 5 years. or a suture.
◈ Straight or curved fracture lines • - This may cause epidural haematoma, venous
◈ 75% of these fractures occur in the parietal bones, 15% in sinus thrombosis and occlusion
the occipital bones, and 5% in the frontal bone

Fracture Suture

Greater than 3mm width (widest at Less than 2mm in width (same width
the center and narrow at the end) throughout)

Runs though both outer and inner Appear lighter on X-ray

lamina of bone (appear darker)

Usually over temporal parietal area At specific anatomic site

Usually runs in a straight line Does not run in a straight line (jagged)
Angular turns Curvaceous
 linear parietal skull
fracture

Bilateral linear parietal

lucency coursing across the
skull. Nondisplaced linear skull fracture
( frontal bone)
 Depressed Skull Fracture
❖ Piece of bone becomes detached and is displaced
towards the brain
❖ Bone of the skull vault being folded (depressed) inward
into the cerebral parenchyma
❖ ~75% occur in the frontoparietal region
❖ May be open (compound) or closed
❖ Open fractures: skin laceration over the fracture or the
fracture runs through the paranasal sinuses and the
middle ear structures

Xray:
• Increased density where one border of the fracture fragment
overlies the adjacent bone
• Fragment lying deep to the skull vault
Depressed fracture (displaced toward the Depressed skull fractures are Depressed skull fracture with
brain) of the parietal bone over the frontoparietal region epidural haematoma

Associated injuries with depressed skull fractures:

extradural hematoma
⮚ Subdural haematoma
⮚ Cerebral contusion
⮚ Subarachnoid haemorrhage
⮚ Pneumocephalus
⮚ CSF leak
 Case Discussion
Mr. A, 49 years old, Malay, male, ◈ Patient was restless and drowsy, was
not in respiratory distress.
Alleged MVA (motorbike vs car),
• He was a motorbike rider ◈ Documented GCS: E2V2M5 (9/15)
• Unsure of mechanism of injury ◈ Not in shock
• Post-trauma, sustained ◈ No any other external injuries or wound
reduced consciousness & ear ◈ Vital signs:
bleeding. i. BP: 175/95 mmHg
ii. PR: 106 bpm
iii. SpO2: 99%
iv. T: 37

Diagnosis: Alleged MVA sustained moderate Traumatic Brain Injury

 1) Effacement of the
adjacent cerebral sulci and
gyri of right temporal lobe
2) The EDH exerts mass
effect, compressing the
ipsilateral right lateral
ventricle and causing
midline shift

Epidural haematoma at the right temporal

region with maximum thickness of 2.7cm. Midline shift to the left.
 ◈ Planned for Right Craniotomy for Evacuation of Blot Clot

Post Op Findings
Reduced midline shift ,
no epidural haematoma
as it has been
evacuated, reduced
mass compression
 Treatment and
04 management
 Referral to nearest hospital
Consider referral of patients with mild head injury to nearest hospital
if:
● GCS of 15 but symptomatic (amnesia, headache, vomiting,
restlessness)
● Age ≥65 years old
● Treated with antiplatelets / anticoagulants
● GCS <15 and/or declining GCS score
● Alcohol intoxication & substance misuse
● Focal temporal blow
● Social issues
● Indicated for head CT
 Management in ED
1.Primary survey according to ATLS guidelines:
a)Airway patency & cervical spine protection
b)Breathing – to detect any intrathoracic injury
c)Circulation & haemorrhage control
d)Disability – incl. GCS, pupil size, reaction to light
e)Exposure – incl. logroll

2.Secondary survey – head-to-toe examinations

Management in ED
3. Head chart (serial GCS, BP,
PR, pupil size) hourly while
awaiting CT or transfer to
another ward / hospital
○ Monitor for signs of
intracranial
hypertension – ↓
pupillary response to
light, hypertension with
bradycardia, posturing
or respiratory
abnormalities
Ward admission / discharge home from
ED
Admission to ward Discharge home
Patients with mild head injury who have been Patients with low-risk mild head injury:
observed for 6 hours in ED should be admitted to
ward if they have: • GCS of 15
● Clinically significant abnormalities on head CT
● GCS <15 • No clinical finding (amnesia, vomiting, diffuse
● Worrying signs headache, LOC)
○ Vomit ≥2 times, seizure, diffuse
• No neurological deficit
headache, amnesia, abnormal
behaviour or neurological deficit • No skull fracture
● Other body system injuries requiring
admission • No risk factors (coagulopathy, age >60 years, previous
● Social problem neurosurgery, pre-trauma epilepsy and/or alcohol
○ Transport issue, no communication, and/or drug misuse)
stay in remote area, suspected abuse
case, no supervision by responsible
adult, or other factors affecting the
monitoring and safety of patients

*Patients should have head CT before admission

 Principles of treatment
Principles of treatment in TBI is to reduce the ICP
• Keep heads up at 30 degrees
• Adequate oxygenation and ventilation
• Analgesia / sedation
• Anticonvulsants
• Fluid management
• Surgical intervention
 Medications for early management
Agitation, pain and seizure may potentially contribute to elevation in ICP, BP and
body temperature.

Even unconscious TBI patients may have increased blood pressure and ICP resulting
from this stress response.

Sedative agents can reduce metabolic stress on acutely injured brain tissue by
decreasing cerebral metabolism and consumption of oxygen in a dose-
• Analgesia / sedation
dependent manner that, in turn, decreases CBF and leads to a reduction in
• Anticonvulsants ICP.
• Intravenous fluids
 Medications for early management
Post traumatic seizure (PTS) defined as a recurrent seizure disorder due to TBI.
1. Immediate seizure (<24 hours)
2. Early seizure (<7 days)
3. Late seizure (>7 days)

Risk factors for PTS

• Analgesia / sedation
• GCS <10/15
• Anticonvulsants
• Cortical contusions
• Intravenous fluids
• Depressed skull fractures
• Early intracranial haematoma
• Wounds with dural penetration
• Prolonged length of coma (>24h)
• Prolonged length of PTA (>24h)
• Damage in the region adjacent to
the temporal sulcus
 Medications for early management

A hypertonic crystalloid solution, is commonly used to decrease brain

water content and reduce intracranial pressure (ICP) while temporarily
• Analgesia / sedation
increasing systolic blood pressure and cardiac output.
• Anticonvulsants
• Intravenous fluids
Mannitol (osmotic diuretics) also helps to reduce ICP.

Isotonic crystalloids (eg normal saline, Hartmann’s solution) is the most

preferred fluid management for resuscitation
 Surgical intervention
Evacuation of haematoma
• Craniotomy (surgical removal of part of the bone from the
skull)
• Burrhole (small hole that is made at the skull to help drain
the hematoma)

Decompressive craniectomy – skull is removed to allow

swelling or herniating brain to expand without being squeezed

Extraventricular drain (EVD) insertion - allow for temporary

drainage of cerebrospinal fluid (CSF) and/or monitoring of
intracranial pressure
 References
● Clinical Practice Guidelines: Early Management of Head Injury in Adults