CASUALTY UNIT

Management of Head
Injury
By Dr. Akinniyi O.T
Clinical Services Dept- NOH Dala

Outline

Introduction
Epidemiology
Clinical presentation
Management
Complications
Prevention
Conclusion

Introduction

Definition: Injury to the cranial vault, content

or covering in isolation or combination.
Associated injuries: Facial, Cervical spine
M:F==2:1, 80% of victims are 15-25yrs
75% of fatalities following motorbike
accidents.
Causation: RTA, domestic violence/assault.
industrial/occupational hazard.
Major disability in patients with
moderate/severe injuries.

Goal of treatment

Control and treat 10 injury while preventing

development of 20 injury.

Apparently trivial but potentially fatal injuries.

Apparently hopeless but potentially.

salvageable injuries.

Hopeless injuries.

Clinical presentation

Hx: Altered or loss consciousness following

trauma

Examination: vitals, GCS, head, ears,

nostrils, eyes, pupillary size, light rxn,
fundoscopy, face focal/lateralizing signs.

Spine
Posturing: decorticate, decerebrate

Chest, abdomen, pelvis, extremities

Investigations

Skull: AP, Lateral, Townes

CT, MRI, Transfontanell scan(<18months)

e/u/cr, rbs, blood gas, serum alcohol, fbc

Vertebral column, CXR, pelvis, extremities

Treatment: At the scene

Quarantine and extraction to safety

Air way and cervical control
Breathing
Control of haemorrhage
AVPU, semi-prone (Lt)
Associated injuries
Transport
Communication with receiving facility

Treatment: In Hospital Care

Resuscitation + primary survey

Secondary survey
Indication and timing of surgical treatment
Surgical options

Management of complications
Supportive care/care of the unconscious

Rehabilitation

Resuscitation + primary survey:

Airway + cervical control:

Breathing: supplemental intranasal O 2, 300 head-up
Circulation: (Anyawu 2000,Richards 2001, P.Singh 2005)
Choice of fluid
Amount of fluid
Duration of fluid therapy
Hypovolaemia at presentation
Hypertension at presentation
Disability: GCS
Exposure

Secondary survey

Hx: medical conditions, lucid interval

Examination: GCS(30min-1hrly), pupils,

lateralizing signs

Review of results: skull x-ray, brain ct, mri

Assessment

Mild +Moderate head injury

Grouping: i-iv based on GCS

i: 9-12

ii: 13-14

iii: 15 with neurologic deficit/ skull fracture

iv: 15 no deficits of fracture

Severe Head injury

GCS 3-8

ICU

Supportive care

Supportive care

HDU/ICU: Continuous Invasive monitoring

Respiration/ Air way
Pressure areas
Eyes
Nutrition
Bladder
Bowel
DVT prophylaxis
Surveillance for nosocomial infection

Conditions complicating head

injury

Cerebral oedema: elevation, hyperventilation,

mannitol.

Seizures.

Raised intracranial pressure: muscle

relaxation, paralysis, controlled csf drainage,
propofol.

Indication and timing of surgical

Rxt

Scalp: Laceration (6hrs).

Skull: Open/ significant depressed fracture.

Brain: intracranial collection, penetrating

injury, persistent csf leakage, lateralizing
signs.

Surgical options

Scalp: 10 closure, flaps, cortical drilling and 20

closure.

Skull: Elevation of depressed skull fractures,

bone grafting, titanium plating, bone cement

Haematoma: Burr Hole(diagnostic/theraputic)

drainage
Dura: 10 suturing, dural patch (water tight)

Brain injury: Debridement, lobotomy

Rehabilitation:

Re-integration into the society

Head injury advice

Complications

Early: seizures, amnesisa, abscess,

encephalitis, meningitis, haematomas

Late: seizures, personality change,

hemiplegias/hemiparesis, vegetative state,
skull osteomyelitis

cosmetic

Prognosis

Severity of initial injury at presentation

Secondary brain injury

Adequacy of treatment

Age

Prevention:

Primary: re-education, sit belts, helmets,

pedestrian

Secondary: diagnosis, timely definitive

intervention

Tertiary: Re-engineering

Conclusion

For those of us still writing exams coupled

with the paucity of updated literature we
should avoid disdain for that which is old
while embracing the new.
While controversies rage on we should give
our patients the best within the context of
current knowledge and evidence.

THANK YOU ALL