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Closed Head Injury

  1. Mild head injury
    1. Most head injuries are mild head injuries.
    2. Many of these patients require only minimal observation after they are assessed carefully, and many do not require radiographic evaluation.
    3. These patients may be discharged if a reliable individual can monitor them.
    4. Patients with mild head injuries typically have concussions.
    5. A concussion is defined as physiologic injury to the brain without any evidence of structural alteration. Q
    6. As many as 30% of patients who experience a concussion develop postconcussive syndrome (PCS).
    7. PCS consists of a persistence of any combination of the following after a head injury: headache, nausea, emesis, memory loss, dizziness, diplopia, blurred vision, emotional lability, and sleep disturbances.
    8. Fixed neurologic deficits are not part of PCS, and any patient with a fixed deficit requires careful evaluation.
  2. Moderate and severe head injury
    1. The treatment of moderate and severe head injuries begins with initial cardiopulmonary stabilization. After a thorough neurologic assessment, a CT scan of the head is obtained.
    2. Most neurosurgeons consider any of the following as indications for surgery in patients with head injuries:
      1. Extra-axial hematoma with midline shift greater than 5 mm, intra-axial hematoma with volume greater than 30 cc, an open skull fracture, or a depressed skull fracture with more than 1 cm of inward displacement. Q
      2. In addition, any temporal or cerebellar hematoma that is more than 3 cm in diameter is considered a high-risk hematoma because these regions of the brain are smaller and do not tolerate additional mass as well as the frontal, parietal, and occipital lobes.
      3. These high-risk temporal and cerebellar hematomas usually are evacuated immediately Q
    3. If no surgical lesion is present on the CT scan, treatment of the head injury begins.
    4. The first phase of treatment is to institute general measures.
    5. Once appropriate fluid resuscitation has been completed, intravenous fluids are administered to maintain the patient in a state of euvolemia or mild hypervolemia.
    6. The use of anticonvulsants in TBI is a controversial issue.
    7. When treating elevated ICP, remember that the goal of treatment is to optimize conditions within the brain to prevent secondary injury and to allow the brain to recover from the initial insult.
    8. CSF accounts for 2-3% of total intracranial volume.
    9. In adults, total CSF production is approximately 20 cc/hour or 500 cc/day.
    10. In many patients with TBI who have elevated ICP, a ventriculostomy may be placed and CSF may be drained.
    11. Removal of small amounts of CSF hourly can result in improvements in compliance that result in significant improvements in ICP.
    12. Brain or tissue comprise 85-90% of the total intracranial volume.
    13. When significant brain edema is present, it causes an increase in the tissue component of the total intracranial volume and results in decreased compliance and increased ICP.
    14. Treatments for elevated ICP that reduce total brain volume include diuretics, perfusion augmentation (CPP strategies), metabolic suppression, and decompressive procedures.
    15. Mannitol, an osmotic diuretic, is the most common diuretic used.
    16. Mannitol is a sugar alcohol that draws water out from the brain into the intravascular compartment.
    17. The standard dose ranges from 0.25-1 g/kg, administered every 4-6 hours.
    18. Other diuretics that sometimes are used in patients with TBI include furosemide, glycerol, and urea.
  3. Penetrating trauma
    1. The treatment of penetrating brain injuries involves 2 main aspects:-
      1. The first is the treatment of the TBI caused by the penetrating object. Penetrating brain injuries, especially from high-velocity missiles, frequently result in severe ICP elevations which is identical to the treatment of closed head injuries.
      2. The second aspect of penetrating head injury treatment involves debridement and removal of the penetrating objects.
  4. Head injury in children
    1. Head injuries in children differ from head injuries in adults in several ways.
    2. Children tend to have more diffuse injuries than adults, and traumatic intracerebral hematomas are less common in children than in adults.
    3. In addition, early posttraumatic seizures are more common in children than in adults.
  • Subdural haematomas may be classified into acute, subacute and chronic.
    1. Acute subdural haematoma - less than 3 days. Hyper dense (white on CT)
    2. Subacute subdural haematoma - 4-21 days. Isodense (similar to brain on CT)
    3. Chronic subdural haematoma - more than 21 days. Hypo dense (dark on CT)
  • Occur much more frequently from tearing of bridging veins.
  • May be associated with arterial lacerations on the brain surface.
  • Subdural haematomas normally cover the entire surface of the hemisphere.
Acute Subdural.
Up to 1/3 of patients have a lucid period. Majority are drowsy/ comatosed. Arousable patients may complain of unilateral headache and frequently have a slight enlarged pupil on that side (5-10% contralateral). Brain damage more severe, prognosis worse than for extradural haematomas. Bilateral in about 1/3 of cases, compared to 3% in extradural haematomas.
  1. Chronic Subdural haematoma. Q
    1. Preceding trauma less clear.
    2. 20-30% give no history of preceding trauma (esp. elderly patients with bleeding diathesis).
    3. History stretching weeks or month of:
      1. Slowed thinking.
      2. Confusion.
      3. Changes in personality.
      4. seizures.
      5. +/- mild hemiparesis.
      6. Fluctuation in the level of consciousness may occur.
      7. May be bilateral.
      8. Initially usually diagnosed as stroke, brain tumor, drug intoxication, depression, and senile or other dementia.
        1. Patient may present with “spells” of hemiparesis of aphasia lasting for 10min and indistinguishable from TIA’s
        2. CT: Low-density mass over convexity of the hemisphere 2-6 weeks after the initial bleed, may show only a shift of the midline structures.
        3. LP- may cause worsening tissue shifts and should be avoided but if done will demonstrate xanthochromia +variable RCC’s Q
      9. Treatment
        1. Glucocorticoids alone may suffice in some cases.
        2. Surgical evacuation is most often successful.
        3. Pseudomembranes that grow from the dura and encapsulate the region require surgical resection to prevent recurrent fluid accumulation.
        4. Small haematomas are largely resorbed and only organising membrane remains, which may become calcified in time.
  2. Extradural Haematomas. Q
    1. Young age group as the dura can more easily be striped away from bone.
    2. A fracture overlies the haematoma in nearly all (95%) adults and most (75%) children.
    3. Features of increased ICP may develop:
      1. Headache
      2. Deteriorating conscious state
      3. Focal neurological signs (dilated pupil, hemiparesis)
      4. Change in vital signs.
  3. Treatment
    1. Urgent CT as soon as the diagnosis is suspected.
    2. In a rapidly deteriorating patient an infusion of mannitol or frusemide may be useful to buy to for the patient to be rapidly transferred to the operating theatre.
    3. It is a surgical emergency and Urgent evacuation is needed.
    4. Prognosis is excellent if haematoma is drained early.
Most common cause of an extradural is a torn middle meningeal artery but also extradural veins, the superior sagital veins, transverse sinus or posterior meningeal artery.
  1. Cervical Spine
    1. All patients with head trauma or maxillofacial trauma should be presumed to have an unstable cervical spine injury until positively excluded.
    2. Absence of neurological deficit does not exclude cervical spine injury.
    3. Examination of the c-spine is impaired in comatosed patients
This injury is known as extension teardrop fracture. This injury is secondary to a hyperextension mechanism and usually involves the second cervical vertebrae. It is seen most often in the elderly.
This injury is potentially unstable.
This is known as a hangman's fracture and consists of fractures through the pedicles of C-2 (traumatic spondylolithisis of the axis). The injury occurs with hyperextension and commonly, following car accidents.
In this patient with little displacement, the anterior and longitudinal ligaments are intact and the injury is relatively stable. With marked anterior displacement, the ligaments are ruptured and the injury is unstable.
This is an injury known as a bilateral facet dislocation. This injury occurs with hyperflexion (car accident or dive into pool, etc.. The injury is quite unstable and the patient is virtually always a quadraplegic (poor prognosis).
Treatment in the ED consists of supportive care, high dose steroids, and placement of a halo. Traction is placed until the fracture is reduced.
C5/C6 dislocation, fracture
  1. Neck Trauma Q  
    1. Penetrating injuries of the anterior neck that violate the platysma are considered significant because of the density of critical structure in this region.
    2. Selective management is based on the neck and is divided into three zones.
      Zone 1 (Thoracic outlet) – between the clavicles and cricoid cartilage
      Zone 2 – between the cricoid cartilage and the angle of mandible.
      Zone 3 – Above the angle of mandible
Ref: Schwartz's Principles of Surgery 9th Edition Ch 7
  1. Chest Trauma
    1. The major pathophysiologies encountered in blunt chest trauma involve derangements in the flow of air, blood, or both in combination. Blunt trauma commonly results in chest wall injuries (eg, rib fractures).
    2. Direct lung injuries, such as pulmonary contusions, are frequently associated with major chest trauma and may impair ventilation by a similar mechanism. Shunting and dead space ventilation produced by these injuries can also impair oxygenation.
    3. Space-occupying lesions; pneumothoraces, hemothoraces, and hemopneumothoraces, interfere with oxygenation and ventilation by compressing otherwise healthy lung parenchyma.
Primary survey chest injuries Secondary survey chest injuries
Airway obstruction Pulmonary contusion
Tension pneumothorax Myocardial contusion
Open pneumothorax Aortic disruption
Massive haemothorax Traumatic diaphragmatic hernia
Pericardial tamponade Tracheobronchial disruption
  Oesophageal disruption
  • Lab studies
    1. Complete blood cell count; Arterial blood gas; Serum chemistry profile; Coagulation profile; Serum troponin levels (Troponin is a protein specific to cardiac cells.
    2. Elevated serum troponin I levels correlate with the presence of echocardiographic abnormalities in patients with possible blunt cardiac injuries.
  • Imaging studies Q
    Chest radiographs:
    1. A CXR is an important in the diagnosis of many conditions, including chest wall fractures, pneumothorax, hemothorax, and injuries to the heart and great vessels (eg, enlarged cardiac silhouette, widened mediastinum).
    2. Tension pneumothorax should be immediately decompressed before obtaining a CXR.
Click to see larger picture
Left hemothorax in a patient with rib fractures.
Click to see larger picture
Right-sided pneumothorax due to a stab wound.
Chest CT scan: Chest CT scans are more sensitive than CXRs for the detection of injuries such as pulmonary contusions.
Thoracic ultrasound: Pericardial effusions or tamponade can be recognized, as can hemothoraces associated with trauma.
  1. Chest injury: Rib fractures Q
    1. Rib fractures are the most common blunt thoracic injuries.
    2. Physical findings include local tenderness and crepitus over the site of the fracture.
    3. Rib fractures do not require surgery.
    4. Pain relief and the establishment of adequate ventilation are the therapeutic goals.
    5. If a fractured rib lacerates an intercostal artery or other vessel, it requires surgical control.
  2. Flail chest
    1. When 2 or more consecutive ribs are fractured in 2 or more places, a free-floating, unstable segment of chest wall is produced. This is called flail chest.
    2. Physical examination reveals paradoxical motion of the flail segment. The chest wall moves inward with inspiration and outward with expiration.
    3. Observation in surgical ICU with symptomatic treatment is treatment of choice if SPO2 level normal.
    4. If hypoxemia even patient is oxygen Endotracheal intubation and positive pressure mechanical ventilation is treatment of choice. Q
    5. Fixation of ribs required only when thoracotomy required for another indication or when SPO2 level low even patient is on IPPV.
    6. Various operations have been devised for correcting flail chest.
    7. These include the application of external fixation devices or the placement of plates or pins for internal fixation.
Chest x-ray will show Indications of intubations are:
Multiple rib fractures Significant other injuries (ISS >50)
Underlying lung contusion Respiratory rate more than 35 per min
Hemopneumothorax Partial pressure oxygen less than 8.0 kPa
  Partial pressure carbon dioxide greater than 6.6 kPa
  Vital capacity less than 12 ml / kg
  Right to left shunt of more than 15%
  1. Pneumothorax
    1. Pneumothorax is most frequently caused when a fractured rib penetrates the lung parenchyma.
    2. Physical examination demonstrates decreased breath sounds and hyperresonance to percussion over the affected hemithorax.
    3. All patients with pneumothoraces due to trauma need a tube thoracostomy.
    4. The chest tube is connected to a collection system and placed to water seal.
  2. Hemothorax
    1. The accumulation of blood within the pleural space can be due to bleeding from the chest wall (eg, lacerations of the intercostal or internal mammary vessels attributable to fractures of chest wall elements) or to hemorrhage from the lung parenchyma or major thoracic vessels.
    2.  Most hemothoraces are associated with a decrease in breath sounds and dullness to percussion over the affected area.
    3.  Hemothoraces are evacuated using tube thoracostomy.
    4. Large, clotted hemothoraces may require an operation for evacuation to allow full expansion of the lung and to avoid the development of other complications such as fibrothorax and empyema.
    5. Thoracoscopic approaches can also be used.
Points to remember:
  1. Pleural cavity can hold up to 3 litres of blood.
  2. One litre may accumulate before apparent on chest x-ray (angles are obliterated at 500 ml).
  3. 90% due to injury to internal mammary or intercostal vessels.
  4. 10% from pulmonary vasculature.
  5. Bleeding usually stops when lung re-expanded.
  6. Most require no more than simple chest drainage.


Indications for surgery:
Indications for emergency room thoracotomy Indications for urgent thoracotomy
  1. Acute pericardial tamponade unresponsive to cardiac massage
  2. Exsanguinating intra-thoracic haemorrhage
  3. Intra-abdominal haemorrhage requiring aortic cross clamping
  4. Need for internal cardiac massage
  1. Chest drainage >1500 ml or >200 ml per hour or 100 ml per 15 min.
  2. Large unevacuated clotted haemothorax
  3. Developing cardiac tamponade
  4. Chest wall defect
  5. Massive air leak despite adequate drainage
  6. Proven great vessel injury on angiography
  7. Proven oesophageal injury
  8. Proven diaphragmatic laceration
  9. Traumatic septal or valvular injury of the heart
  1. Open Pneumothorax: This injury is commonly caused by penetrating mechanisms but may occur with blunt thoracic trauma.
    1. Patients are typically in respiratory distress.
    2. Examination reveals a chest wall defect that is larger than the cross-sectional area of the larynx.
    3. The affected side demonstrates a complete loss of breath sounds.
    4. The increased intrathoracic pressure can shift the contents of the mediastinum to the opposite side, decreasing the return of blood to the heart, leading to hemodynamic instability.
    5. Treatment for an open pneumothorax consists of placing an occlusive dressing over the wound. A tube thoracostomy is then performed.
    6. After initial stabilization, wound debridement and closure is done.
  2. Tension pneumothorax Q
    1. With a tension pneumothorax, air continues to leak from an underlying pulmonary parenchymal injury, increasing pressure within the affected hemithorax.
    2. Patients are in respiratory distress, breath sounds are absent, and the hemithorax is hyperresonant.
    3. The trachea is deviated away from the side of the injury.
    4. The mediastinal contents are shifted away from the affected side. Immediate therapy for this life-threatening condition includes decompression of the affected hemithorax by needle thoracostomy.
    5.  A large-bore needle (ie, 14- to 16-gauge. is inserted through the second intercostal space in the midclavicular line. A tube thoracostomy is then performed.
  3. Pericardial tamponade
    1. Haemopericardium prevents diastolic filling of the heart
    2. Classic signs are Beck's triad
      1. Hypotension,
      2. Venous distension &
      3. Muffled heart sounds Q
    3. May be associated with pulsus paradoxus
    4. Chest x-ray shows a globular heart
    5. Unstable patient requires urgent thoracotomy
    6. In stable patient diagnosis can be confirmed by
      1. Echocardiography / Pericardiocentesis
    7. Subxiphoid pericardiotomy is both a diagnostic and therapeutic procedure.

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