Initial management of head injury

The initial management of head injury is very important to reduce the morbidity and mortality associated with the condition. The initial care impacts significantly on the eventual outcome and if not properly done, it may make nonsense of any eventual specialist neurosurgical care.

The key aspects in the management of patients following head injury involve:
• accurate clinical assessment of the neurological and other injuries
• determination of the pathological process involved
• accurate assessment of changes in the neurological status of the patient; this indicates an improvement, progression or change in the pathological processes.

At the injury site, immediate care involves careful extraction of the injured individual (e.g from a car wreck, collapsed building, gutters, etc), rapid restoration and maintenance of an adequate airway, protection of the cervical spine, ventilation, essential circulatory resuscitation, first aid treatment of other injuries and the urgent transfer of the patient to hospital.

It is essential to avoid hypoxia and hypotension as these will cause further brain
injury (secondary brain damage). The ‘ABC’ of resuscitation gives a good guide for the initial management of the head-injured patient like other trauma patients.

Clinical Features of Hydrocephalus

Clinical presentation of hydrocephalus depends on the age of the affected individual and the rate of CSF accumulation. In infants, the most striking feature is the abnormal increase in the size of the head whereas in adults, it commonly presents with features of raised intracranial pressure.

In young children, hydrocephalus could present with any combination of the following symptoms and signs:

• Abnormally large head; usually with the rate of growth of the cranium greater than that of the face (craniofacial disproportion)
• Irritability
• Poor neck/head control
• Poor developmental milestone attainment/loss of previously attained milestones such as social amile, neck control, sitting, walking and talking
• Nausea and vomiting
• Bulging fontanelle(s)
• Widening of the cranial sutures (sutural diastasis)
• Prominent, enlarged and engorged scalp veins
• ‘Setting sun sign’ or sunset appearance of the eye due to paralysis of upward gaze (Parinaud syndrome) from pressure of the accumulated CSf in the suprapineal recess on the tectum of the midbrain
• Sixth nerve (abduscens) palsy (due to its long intracranial course)
• Macewen’s sign: cracked pot sign on percussion of the skull
• Miscellaneous findings
o Hyperactive reflexes
o Irregular respirations with apneic spells

In older children/adults, it presents with features of increased ICP:
• Headache
• Nausea and vomiting
• Gait abnormalities
• Papilloedema
• Upward gaze palsy
• Sixth nerve palsy

If the ventricles enlarge slowly, the condition may initially be asymptomatic.
The classic triad of normal pressure hydrocephalus is:
• Dementia
• Urinary incontinence
• Gait ataxia

Causes of Hydrocephalus

The conditions causing hydrocephalus include the following:

• Excessive CSF production by the choroid plexuses
o Choroid plexus papilloma

• Blockage in the CSF circulation, either within the ventricle, or on the outside of them
o Aqueductal stenosis
o Tumours
o Chiari malformation especially types I and II
o Dandy-Walker malformation
o Intraventricular haemorrhage
o Meningitis
o Spinal tumour
o Myelomeningocoele

• Impairment of CSF absorption by the arachnoid villi.
o Meningitis
o Subarachnoid haemorrhage

The causes enumerated above could also be classified into congenital or acquired.

Hydrocephalus: Introduction

Hydrocephalus is a neurosurgical condition in which there is excessive accumulation of brain water (called cerebrospinal fluid) in the head. Hydro = water; cephalus = head. It is rare but certainly present in our community.

Many of the children, and alas! Adults that you see around with big heads suffer from this condition. Do not stigmatize the sufferer, it is definitely not his/her making.

The causes of the condition are many; some are congenital (occur before birth) while some others are acquired (contracted after birth). To properly understand the causes of hydrocephalus, you need to appreciate the formation and flow of the brain water. A simple overview of this is as follows:

• The brain has large spaces within it called the ventricle (four of them, called right lateral, left lateral, third & fourth)

• The ventricles communicate with a space surrounding the brain, called the subarachnoid space through openings (foramina in the 4th ventricle)

• The subarachnoid space in turn coomunicates with a similar space surrounding the spinal cord

• Cerebrospinal fluid (CSF) is produced by flower like structures in the ventricles called the choroid plexus

• The fuid circulate in the ventricle and into the subarachnoid space (around the brain and the spinal cord)

• The fluid get absorbed into the blood stream via finger-like structures called arachnoid villi located in the coverings of the brain

• CSF production is in dynamic balance with absorption to prevent its accumulation.

From the foregoing, you would probably have deduced that hydrocephalus can result from:
1. Excessive CSF production by the choroid plexuses
2. Blockage in the CSF circulation, either within the ventricle, or on the outside of them
3. Impairment of CSF absorption by the arachnoid villi.

Simple isn’t it? You don’t have to be a genius to understand this. Watchout for my updates on this topic. I will appreciate your feedback on how useful you think this introduction is. I will also make myself available on this site to answer any question that bothers you about this very important condition. In addition, I shall appreciate your comments on the topic.

Join this discussion.

The Glasgow Coma Scale

The Glasgow Coma Scale was introduced by Graham Teasdale and Lord Jennet in 1974. Till date, it is the most widely used and accepted measure of level of consciousness. The scale has 3 parameters as defined below. Obtainable scores are from 3 to 15 with scores below 15 indicating diminished levels of consciousness. A patient with a score of 8 or below is said to be in coma.

The scale is renowned for its simplicity, reproducibility and objectivity. It provides a fast means of patient assessment which can be used by various cadres of health workers including paramedics, nurses and physicians.

Parameter Numerical Value

Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1

Best Verbal Response
Orientated 5
Confused 4
Inappreopriate 3
Incomprehensible sounds 2
None 1

Best Motor Response
Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Abnormal flexion 3
Extension to pain 2
None 1

TOTAL 3-15

Head Injury-Overview

Head injuries are a major cause of morbidity and mortality in all communities. Trauma is the third most common cause of death in the United States, exceeded only by cerebrovascular disease and cancer. Trauma is the leading cause of death in youth and early middle age and the death is often associated with major head trauma. Head injury contributes significantly to the outcome in over half of trauma-related deaths.

There are approximately 2.5 deaths from head injury per 10 000 population in Australia and neurotrauma causes approximately 3.5% of all deaths. Road traffic injuries (RTI) are responsible for about 65% of all fatal head injuries in Australia. In developing economies, trauma is the leading cause of death with many of them resulting from road traffic injuries (motor vehicles or motor cycles {AKA Okada in Nigeria}).Other causes include fall from heights (particularly in children), sports injuries and assault.

There is a wide spectrum of head injury from mild concussion to severe brain injury resulting in death. The management of the patient following a head injury requires the identification of the pathological processes that have occurred. Adequate attention must be paid to associated injuries whose management may sometimes take precedence over the head injury management.

CLASSIFICATION
The various ways of classifying head injury are:
1. According to aetiology e.g RTI, fall, sports

2. According to mode of injury:
a. Blunt
b. Penetrating

3. According to the state of the scalp and skull
a. Closed: in which scalp and skull are intact
b. Open: in which both are breached

4. According to the Glasgow Coma Score (GCS)
a. Mild: GCS 13-15
b. Moderate: GCS 9-12
c. Severe: GCS 3-8

NB: a. Coma is GCS < 8
b. Some workers classify GCS 3 - 4 as critical head injury

ABC of Resuscitation

Resuscitation of the injured patient is often an Herculean task for the untrained health workers. Similarly, some students find it difficult answering questions on the initial care of the acutely injured patient. In this entry I have tried to summarise, in simple language, the essential components of resuscitation, specifically for use in head injury, but with wide-ranging applications in other trauma cases. This information is also useful to the members of the public who may at one time or the other find themselves at accident scenes and have to provide initial care for the injured.

The components are:

• Airway and cervical spine control: check for, and maintain airway patency. Remove debris or food particles which may occupy the mouth and the upper airway thereby preventing adequate air entry. Jaw thrust and/or traction on the tongue might be needed to keep the airway patent. Insertion of oropharyngeal airways, and when indicated/available, oro- or nasotracheal intubation are essential in keeping the airways open. The patient may die rapidly from asphyxia if this initial step is not quickly and meticulously carried out. In doing all these, it is essential to protect the cervical spine which must be assumed to have been injured in all unconscious patients and in those who have sustained significant impact to the cranium, face, neck and upper chest as well as those involved in high-velocity impacts and falls from height.

C-spine protection can be achieved with:

o Rigid neck collars
o Head strappings
o Supportive sand bags placed on each side of the neck

• Breathing: If there is no spontaneous breathing, assisted breathing is essential once airway patency is confirmed. Mouth-to-mouth breathing (Kiss of life; through an handkerchief), ambu-bagging and mechanical ventilation are done as necessary

• Circulation: a quick assessment of the patient’s circulation is done; radial pulse is palpated and BP measurement carried out. Maintenance of the circulation is done using intravenous fluids (crystalloids and colloids) as necessary. This is particularly important in the poly-traumatized patients with haemorrhage. If the initial circulation is not optimal, a search must be made for extracranial bleeding sites as intracranial bleed is not sufficient to cause circulatory collapse except in infants and very young children.

• Drugs may need to be administered. Commonly used drugs in head injury includes mannitol, analgesics, H2-receptor blockers/proton pump inhibitors, inotropic agents, anaesthetic agents, tetanus prophylaxis, etc. Watch-out for a review of these drugs. It is important to also adequately assess the dysfunction of the nervous system

• Environment: it is important to ensure that the environment in which care of the patient is done is safe to prevent further injuries to the patient as well as the care givers

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