HEAD INJURY

AN INTRODUCTION

AGUS BUDI SETIAWAN

NEUROSURGERY DEPARTMENT
HEAD INJURY

The Most Common Case

The Outcome is Still A Big Problem

EVIDENCE BASED MEDICINE

GUIDELINES
HEAD INJURY

Declining mortality rate in severe head

injury ( 50% to 36% between 1970 & 1980 )
The most probable cause is debatable

Quality Improvement in
Emergency Medical Services
Better application of critical
care methodologies
WHAT IS THE GOAL ?
To Facilitate Healing
To Prevent Secondary Brain Damage

Maintain An Optimal Milieu

Uninjured Functioning
Neuron Cell

Optimal milieu
Injured
Neuron
Suboptimal milieu

Fatally Damaged Dead Cell

Neuron
HOW TO MAINTAIN AN
OPTIMAL MILLEU ?
• Providing Good Oxygenation >< cerebral ischemia

• Preventing Hyponatremia >< seizure

• Preventing Hyperglycemia >< cerebral edema

WHAT IS OUR ENEMY ?
• High Intracranial Pressure
• Reduced Blood Pressure
• Hypoxia
High Intracranial Pressure caused by :
• Hematoma
• Brain swelling / cerebral edema
• Pain

Reduced Blood Pressure caused by :

• Hypovolemic shock
• Severe Dehydration

Hypoxia caused by :

• Pulmonary complication : hemato/pneumothorax

• aspiration pneumonia, lung contusion
CLASSIFICATION
• Mechanism
• Closed
• Penetrating

• Severity
• Mild
• Moderate
• Severe

• Morphology
• Skull Fracture

• Intracranial Lesion
• Mechanism

High Velocity

CLOSED

Low Velocity

Gunshot Wound

PENETRATING

Other open
injuries
• Severity
MILD

GCS 13 - 15

GLASGOW MODERATE
COMA SCALE GCS 9 - 12
TEASDALE AND
JENNETT 1974
SEVERE
GCS 3 - 8
• Morphology
VAULT
LINEAR OR STELLATE
DEPRESSED

SKULL

FRACTURES
BASILAR

CSF LEAK
NERVE VII PALSY
• Morphology
FOCAL
EPIDURAL
SUBDURAL
INTRACEREBRAL

INTRACRANIAL

LESION DIFFUSE

MILD CONCUSSION
CLASSIC CONCUSSION
DIFFUSE AXONAL
INJURY
• EVALUATION

Loss of
consciousness

Headache &
vomitting
HISTORY OF
ILLNESS
Seizure

Mechanism ?
• EVALUATION

State of A B C

G C S, pupil, motoric

Sign of Skull Base

PHYSICALL Fracture
EXAMINATION
Wound & Brain
exposed

Other injuries
• MANAGEMENT

• A B C, & C Spine Stabilization

• Nasogastric Tube
• Pharmalogical Intervention
• Surgical Intervention
• MANAGEMENT

A B C, & C Spine Stabilization

• Clear the airway

• Head extension with neck collar

• Oropharyngeal tube

• Oxygen supply 6 – 10 l/minute with face mask

• IV line

• Obtain Cervical X Ray and Head CT Scan

• MANAGEMENT

Nasogastric tube
• Preventing aspiration

• Beware of anterior skull base fracture

Pharmalogical Intervention
• Pain killer

• Mannitol 0,5 – 2 mg/ KgBW every 4 – 6 hour

• Anti convulsant agent

• Antibiotic
RADIOLOGICAL EXAMINATION

Skull X Ray
• Skull bone

• Lack of information especially for brain and soft

tissue

Head CT Scan
• Gold standard

• Available for reconstruction

• Mandatory in patient with loss of consciousness

Surgical Intervention

• Indication
• When
• How
• Complication
Surgical Intervention

Indication
• Mass effect : midline shifting > 5 mm
• Depressed fracture > 1 diploe
• Penetrating head injury
• Headache