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
Neuron

Functioning
Cell
Optimal milieu

Injured
Neuron
Suboptimal milieu

Fatally Damaged
Neuron

Dead Cell

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
COMA SCALE
TEASDALE AND
JENNETT 1974

MODERATE
GCS 9 - 12
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

HISTORY OF
ILLNESS

Headache &
vomitting
Seizure
Mechanism ?

 EVALUATION
State of A B C
G C S, pupil, motoric
PHYSICALL

Sign of Skull Base

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