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Management of Head Injuries, Dr Henry Marsh

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Summary

This session will discuss the management of head injuries and traumatic brain injury in both closed and open scenarios, taking into account the types of injuries, their causes, and the secondary damage that can occur. It is essential listening for medical professionals who want to understand the basic principles of management and anticipate the signs of a threatening intracranial pressure in order to limit secondary damage.
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Learning objectives

Learning Objectives: 1. Understand the classification of head injuries and when they may be open or closed. 2. Utilize the concept of post-traumatic amnesia using questions for patients to assess severity of primary impact damage. 3. Recognize signs of secondary brain damage and the consequences of an expanding hematoma. 4. Explain the Monroe-Kelly Doctrine of how the restraint of a closed skull box affects brain damage. 5. Appreciate the differences between closed and open head injuries and corresponding management approaches.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Oh, I understand. Right. Good morning. Uh I'm gonna talk to you briefly about the basic management of head injuries more properly known as traumatic brain injury. This is uh uh why let this move forward? Um Yeah, this is a, a major cause of death and morbidity worldwide. Estimated about 55 million people a year suffer significant traumatic brain injury. I will start by talking about the classification of head injuries. I'll then talk a little bit about basic physiology of the brain within the skull. A little bit about the causes and mechanisms of traumatic brain injury and finally about the principles of management. Now, in terms of classification, he can be closed or they can be open if they're open, it means the skin, uh and skull has been broken and the brain is exposed to the outside world. In civilian practice. Road traffic accidents falls down staircases, assaults, things like that. Most head injuries are closed. There'll be some open ones in military practice. As in the dreadful war in Ukraine at the moment, most will be open with penetrating injuries from shrapnel and bullets. The causes are fairly obvious falls in civilian society are the commonest road traffic accidents, particularly in developing countries with large numbers of motorbikes, assaults and then of course gunshot and shrapnel wounds in in war zones and also in countries like America where there is an awful lot of gun crime. A large proportion of closed injuries in civilian practice involve alcohol in terms of the mechanisms. The basic concept I want you to understand is between primary impact damage and secondary damage management is all about trying to limit secondary damage. We cannot undo the primary impact damage. A blunt blow on the head causing a closed injury will cause violent acceleration and deceleration of the brain within the skull because this brain floats in spinal fluid depending on the force involved, primary impact damage will occur. It can cause instant neurological dysfunction, varying from the rather poorly defined concept of concussion of up for a few seconds of er immediate death or it again in a persistent vegetative state. Now, we cannot do anything to undo the primary impact damage. The primary impact damage is tearing and shearing of white matter and to some extent gray matter which causes diffuse axonal injury. And it can also cause blood vessels to rupture. This rupturing of blood vessels can lead to secondary damage. The way to think about the brain in traumatic brain injury is like a jelly, but it is a jelly in a box. And if you shake the box, the jelly will move around. And if it's a lot of force involved, the jelly will tear and fragment in places and if the force is bad enough, this will cause catastrophic injury. This is an example of diffuse brain damage from severe primary impact. A CT scan on the left showing the typical picture of a little punctate hematomas, little punctate hemorrhages which reflect the fact the whole brain has been damaged by force. We don't normally get MRI scans acutely because the scan takes too long. But this the pictures on the right show an MRI scan of diffuse injury. And you can see on, on the right hand image areas of of damage, the little black spots, all of the brain is damaged to a greater or lesser extent in severe primary impact damage. As I said a moment ago, we cannot undo this primary impact damage which can be mild or it can be catastrophic. The best measure of whether somebody has suffered a significant primary impact damage, head injury or not is post traumatic amnesia. People often get very muddled about this and muddled about retrograde amnesia and other phrases. Pt A post traumatic amnesia is very simple. It is simply the first thing the patient can remember after the injury and the longer the gap between the injury and what they when they can start remembering again. This is a pretty reliable measure of whether the brain as a whole has suffered severe primary impact damage or not. So you simply ask the pa assuming the patient's conscious or when they regain consciousness, you say, do you remember lying on the ground after the accident? Do you remember the ambulance arriving? What is the first thing you can remember in hospital? In severe cases, people never regain any memory at all. In moderate to severe cases, it can be anything between a few days and a few weeks. But PT A is a pretty reliable guide Once the patient is conscious as to whether the brain as a whole has suffered severe primary impact damage or not simply ask the patient, what is the first thing they can remember? That is post traumatic amnesia. Secondary damage occurs after the primary impact and it can take the form of bleeding if blood vessels have been ruptured and swelling and ischemia and you can end up with a vicious circle, the brain becomes swollen as any tissue becomes swollen. If it is bruised, this puts up the pressure in the head. If there is a blood clot forming as well, the intracranial pressure, intracranial pressure will rise and it can become lifethreatening if the patient has a blocked airway or lung injuries or if they're bleeding from multiple fractures. So they're hypotensive, this will exacerbate the problem because the mean the cerebral perfusion pressure will drop because there's less oxygen getting to the brain and less blood. The cerebral perfusion pressure is simply the mean arterial pressure minus the intracranial pressure. And if you have an expanding blood clot if you have expanding contusions and swelling of the brain. Remember your Monroe Kelly doctrine, but the skull is a closed box. The cerebral perfusion pressure will become critically compromised. And the normal function you need a ce perfusion pressure between 60 80 mg of mercury. Remember again, the pressure volume curve of the horizontal X axis shows the intracranial volume. And the intracranial pressure is on the vertical y axis as you increase, increase the intracranial volume with a blood clot forming with or without the brain swelling because of ischemia. Initially, the um the pressure only rises a little bit and then once ceres spinal fluid has been squeezed out of the skull trying to maintain the pressure, you then rapidly decompensate and then a very, very steep rise in intracranial pressure will occur with only a small further increase in volume. Which is why with the classic traumatic extradural hematoma, people can go from being a little bit sleepy and confused with a fixed dilated pupil to be being dead within 30 minutes. And I've seen that quite often alas in my professional career. So the management of secondary damage, expanding hematomas, in particular, in particular can be a real medical neurosurgical emergency. Although it is only in a small proportion of cases, this diagram shows an expanding hematoma on the left as the hematoma gets bigger, the intracranial pressure rises. There is the pressure gradient between the 10 between the um infratentorial compartment and the supratentorial compartment. And classically with a hematoma on one side, such as a typical temporal exp hematoma, the medial middle part of the temporal lobe starts to be squeezed like toothpaste out of a tube into the tentorial hiatus. The gap, the hole through it, the midbrain is connected to the brain stem. This puts pressure on the brainstem. And if it is not treated by urgent removal of the blood clot, the brainstem will start to fail. The patient becomes increasingly unconscious. You get a fixed dilated pupil on the side, usually of the clot because the third nerve, the oculomotor nerve is running in there and the patient will die without treatment. This shows a typical extra dual. This is a big extradural. There's a lot of midline shift that is a lifethreatening extradural but not every extra dual needs to be removed. This is a small one in an elderly patient with a shrunken brain with lots of space. So probably this extradural could be treated conservatively. So the point of this slide is to say, not every extradural is is a life-threatening emergency. It's a question of size. And in general terms, the elderly brain can cope with um expanding hematoma is better than a young brain. As I said earlier, when the medial part of the temporal lobe, in particular, the uncus is forced into the tentorial hiatus like that. Um you get a fixed dilated pupil on the side of the clock. Typically, first of all, the patient becomes increasingly sleepy and confused. The pupil loose, stops reacting to light and then starts to dili dilate and a truly fixed dilated pupil is very big. Indeed, this is an emergency sign. A catastrophic sign of impending death from cerebral herniation, Tenorio uncle herniation. Just to repeat that you have, the patient becomes increasingly drowsy and confused as measured by the Glascow coma scale which I'll discuss in a moment. You lose a pupil like reflex, followed by dilatation on the side of the blood clot. And then there's a further deterioration and conscious level. This can go on over a matter of minutes through the gasp through flexion, abnormal flexion extension to death. If not treated, then you are bilateral fixed idea to pupils. In general terms. Once a patient with TBI traumatic brain injury has bilaterally fixed idea to pupils, it is too late and it is a mistake to treat them in any way. This is an example of an acute subdural hematoma when the bleeding is underneath the Jura. But outside the brain, it is typically associated with damage to the brain itself right from the start. Whereas an extra dural hematoma is associated with a skull fracture, tearing the meningeal vessels on the jura on the meninges. So, in theory, with an extradural hematoma, the brain is not damaged. If you operate quickly enough with an acute subdural, they usually are associated already with the degree of primary impact damage and the prognosis in general terms is worse. And this is another example of a different form of hemorrhage. You get after blunt head injury, called cerebral contusions. And as you can see, the frontal lobes here have have become profoundly hemorrhagic on this side is a milder case. Um and this, this is damaged brain, you can to some extent remove damaged brain if it is swelling and causing a lifethreatening um problem, but you cannot undo the original damage done to the brain when the bleeding took place. One of the problems is cerebral contusions. It is bleeding within the, within the brain as opposed to a subdural or an extra dual is they tend to get bigger over the 1st 48 hours or so. After the injury, a neurosurgeons call this blossoming or ster contusions. And you can see here a small contusion there which a day later has become a lot bigger and the same the same goes there um come back one. So the point about this, this is secondary damage and the purpose of management is to limit how much secondary damage occurs. I'm not going to spend much time talking about open head injuries for the simple reason that the Mon Ray Kelly Doctrine has been broken by the injury. And although it's very dramatic and people get very upset, um if they can see the exposed brain and bleeding, once you stop the bleeding, which often stops on its own. There is no urge. Yes, they need surgery. But the purpose of surgery now is not to treat um intrarenal pressure and cerebral herniation. It is to prevent infection getting in because it's an open injury. And the management is rather different. Therefore, from closed injuries a little bit paradoxically, these dramatic open injuries are less when I make that move, um are less urgent than the closed injuries if there is an expanding hematoma and a deteriorating conscious level. And this is an example of what's called a compound to press fracture. At surgery, the skull, the skull hair has been sting and here the fragments being pulled out and you can see the resulting defect, but this is all neurosurgical management. And I mainly want to concentrate on the acute management for non neurosurgeons. So as I said, the management of traumatic brain injury is to reduce or to prevent secondary damage and an open injury to prevent infection, which needs to be done within 24 48 hours. The management, I'm sure, you know, already the first and in many ways, the most important step is the ABC D if you're in the emergency room or at the site of an accident. The first question always, always, always is airway is, has the tongue blocked the airway? Is there something in the mouth? You have to put the patient in the recovery position. If you're not in the hospital or put an airway in to make sure the airway is clear. Secondly, be the breathing. Is the patient breathing normally or is there a flail chest? Are they chest injuries? Are they in a deep coma? And their respiratory drive is compromised? And you, you need to give the patient oxygen, you may need to intubate them. Third, see the circulation is a patient hypotensive. Have they lost a lot of blood, blood loss can be invisible. For instance, you can lose liters with pelvic fractures without any external evidence of bleeding, you can need a, you lose a lot of blood from scalp lacerations. And by the time you see the patient, the bleeding may have stopped on its own. If the BP is low, there is less blood getting to the brain. This would make worse. Hi, but um ischemia and hypoxic cytotoxic brain damage. So AB BC only LY, you look at the neurological deficit, what is the patient's neurological condition? And the vital thing here is the patient's conscious level because if we want to prevent or limit secondary damage, we need to know what the patient's conscious level was as soon as we can after the accident. And then see if the patient's condition is getting worse because if it's getting worse, we're gonna have to do something about it to stop it getting even worse. And the way the most reliable way of assessing of describing a patient's conscious level is the Glasgow coma scale. I'm not gonna go through it all in detail because you can look it up yourselves. But essentially you look at to see if the patient is opening their eyes on their own. Anyone you're spoken to or not at all, whether they're talking, if they're talking, whether they're confused or not or if they're not make us making confused sounds. Whether they obey command, squeeze my hand, something like that or whether there's no movement, there are numbers and they used a lot and it's a mistake. So Graham Teasdale who created the Glasgow Coma scale told me he greatly regretted introducing numbers because the numbers really was just for writing research papers. So you could compare groups of head injuries. The purpose of the Glasgow coma scale is not to give it to give a number. It is so that when staff hand over, when a when a casualty nurse, A&E nurse hands over to another nurse or a doctor to another doctor, there is a clear understanding of exactly what the patient's conscious level is. Now. If you just give a number up 14 9 10, you don't really know whether the other doctor or nurse is used in the coma scale properly. And it's very hard to visualize just what the patient is like. The point of the coma scale was to provide an accurate, reliable way of describing a patient's conscious level from one doctor or nurse to another. So that deterioration in the patient's conscious level would not be missed. Yes, you can have numbers on a chart but you really need to avoid the numbers when my neurosurgical residents take referral calls. Most of the time the referring doctor says, oh, they're 98 whatever 11 on the coma scale. And my trainees will always then say, break it down. What do you mean? And you'll often find in every day certainly in England clinical practice. If a doctor says over the coma, coma score is nine, he's been told that by somebody else and like Chinese whispers, it becomes increasingly unreliable. Whereas if you say that eye opening only to pain, they're confused, they're not obeying commands. That gives you a much more accurate idea of what the patient's conscious level is. So I plead with you, please don't use numbers. Although I fear that most of you will um de despite my pleas. So the management, firstly, ABC D, that is the most important part of all head injury management, airway breathing circulation, then you assess the neurological deficit, which usually means putting a immobilizing the neck in a cervical collar. If it's a significant fall or a road traffic accident before you have a, a scan or x-ray of the neck, then having stabilized the patient medically, then you decide if a CT scan is indicated and I'll talk about that next. And if the scan is abnormal, then you need a neurosurgical opinion as to whether surgery might be treated or not. So we need close observation used in the Glasgow coma scale. Not using numbers please. Um If the patient is not in deep coma, so if secondary, because if secondary damage is occurring, the first sign is a conscious level deteriorates and you can't do a CT scan every 10 minutes. Um So the patient's conscious level is the best guide we have as to what's going on in the patient's head. Do we need to get a CT scan or another CT scan? Things like that? So the Glasgow came scale is very important um in describing what the patient's conscious level is and whether it's changing if it's a very severe patient injury, if the patient's in coma, you may need to deci with or without a surgical lesion on, on a scan, an extra dual subdural, whatever. Um You may need to decide whether you ventilate the patient, you give them medical treatment for a swollen brain or a decompressive craniectomy. Um This is slightly, this is beyond um this what I'm talking about. So what are the indications for a CT scan? Well, I'm using a number here at the state of time. If the patient is not fully orientated, opening their eyes spontaneously, a and obeying commands, usually get a CT scan. That means now if the patient is confused um and has a score of 13 and if they've not gone back to being fully normal after two hours, these are the standard recommendations in Britain, you should get a CT scan. Then even if you didn't get it to, to begin with, let's say there were 14 on admission, just confused but opening, opening their eyes spontaneously. So you need a low threshold to get a CT scan, which is easily obtained nowadays, but in a patient who's wide awake, fully orientated, the brain commands only in their eyes, you don't need to get a scan routinely. Although modern medicine being what it is that quite often happens, if you suspect an open or a depressed skull fracture, they need a CT scan and if there's signs of a skull base fracture, which I'll talk about in a moment. So in other words, any patient who is in coma, any patient who is confused and not opening, opening their eyes spontaneously should have a CT scan to find out if there is a possibility of a developing secondary damage from hemorrhage or swelling. A posttraumatic epileptic seizure happens quite often in Children usually is benign um and doesn't reflect serious damage, but is also an indication for AC T scan. Um as is a focal neurological deficit of any sort. Although that's rare without a change in the conscious level and vomiting more than once, which again is quite common in Children and usually benign, but can be a sign of raised intracranial pressure. If the patient is drunk, which is often the case, this can complicate life. But this, you should have a low threshold for getting a scan if in doubt. So to repeat that a Glasgow scale, a Glasgow coma scale of 13 which means in effect, confused, not fully orientated, not opening their eyes spontaneously is an indication for a CT scan. A suspected open or depressed skull fracture, signs of skull brace, skull base fracture. A post traumatic epileptic fit a focal neurological deficit and more than one episode of vomiting are all indications for an urgent CT scan. There are two classic signs of a skull base fracture, so called raccoon eyes here, which is when you have a, have a fracture across the anterior fossa floor above the orbits and battle sign, which is bruising behind the ear. You won't usually see these signs without there being impairment of the patient's conscious level. So they usually need AC T scan anyway. But you might see a patient pitch up several hours after the injury and they're now awake and recovered. But with these signs, even though they're now fully orientated and opening their eyes spontaneously, and these patients should have a CT scan. And what do I want you to remember from this talk? First of all, always, always, always ABC D. The management of head injury starts with stabilizing them to make sure they're medically, they're oxygenating, they got a BP, then you look at the deficit, then you use a Glasgow coma scale and hopefully, if you're in the hospital, the the paramedics or the the first responders will have given you an accurate assessment of the coma scale ideally, in words, not in numbers because they may not know how to use it properly. Um And then you can work out whether the conscious level is deteriorating or not. And then you need to get a CT scan if it is indicated and then going on to surgical management from then on. And that is the end of my short introduction to the basic management of head. And thank you very much. Thank you very much doctor. There has been a question in the chat. Um I can read it out to you. Um So someone's asking um I didn't understand why you use um numbers in G gcs. Was it sho often gives you a number, you don't know whether they know how to use a Glasgow coma scale or not. And you often find they don't, for instance, the difference between flexing and abnormally flexing. So if they give you a number, you have to challenge them and say, what actually did you observe? That's why does that make sense if it, I think if and if that person who asked the question has a follow up, they can, they can share that. But in the meantime, uh there's been another one. So someone's asking, how often do you, how often do you use the Glasgow coma scale on the same patient during the day? Sorry if you answer this question. Well, it depends, it depends, it depends on the severity of the injury and what you're worried about. I mean, different hospitals and different protocols. Um I mean, if, if you're, if say it's after an operation and you're worried about postoperative bleeding and you use a coma scale, typically that's every 15 minutes for the first few hours with a head injury and the patient is a little bit confused. The scan shows a very thin extra dual and you made us do it every half hour for the first few hours. But the critical period after a head injury, the main risk of lifethreatening hemorrhage is within the 1st 12 to 24 hours, although it can occur later than that. Thank you. Um There's another one. can we diagnose or figure the problem from the pupil? No, you all you can tell if there's a fixed dilated pupil and the patient's unconscious is there's almost certainly a large hemorrhage. It could be extra dual, it could be subdural, it could be intracerebral on the side of the fixed dilated pupil. But if there are facial injuries and damage to the eye, the dilated pupil may be caused by direct injury to the eye, the so called traumatic mydriasis. But if there's a a poor a deteriorated conscious level, you have to assume the fixed dilated pupil means there is a a high risk of cerebral herniation and death within the next 30 or 30 minutes to an hour. Thank you doctor. Um No one else has written any questions in the chat. If anyone wants to right now or if you have a question you want to say out loud, you can raise your hand using the reactions on zoom and you can speak up if you'd like um while we're waiting for people to see if they have any more questions. Um I'm just gonna post the feedback link in the chat. So please, everyone do fill that in quickly will take only a minute or two. Um And yeah, if you have any questions, please do ask now. Yes, we have a question from uh coo do you want to unmute uh Doctor Glasco comma scale without number only in neurosurgery or no? Everybody, my hospital and all the local hospitals don't use the numbers. The numbers are a mistake. And the man who made the Glasgow comma scale, Teasdale, that is his opinion as well. I know it has become orthodox but it is a mistake. It is a you need to uh use a verbal description because then it's much more accurate. A number is dangerous because you are assuming the person who is reporting to you has accurately assessed the patient and they may not know, they may not really know how to use the cone scale. That is why the numbers are a pseudo it's sort of pseudoscience. It makes things sound more accurate. Than they really are. Uh Sure, thank you, doctor. Thank you. Um, anyone else with a question you'd like to unmute for or you wanna write in the chart and I'll read it on your behalf. Take the opportunity now. Oh, someone's asked. Do you also use this scale in Children? Yes. There's a, it's more difficult, there is a modified one in Children in pre Children. You talk about whether they can be consoled or not. It's a lot less accurate. You'd have to look it up on the internet. There are various ways of using the Glasgow Chemco in kids, but it is less reliable in young Children for obvious reasons. Thank you doctor. Um Any final questions from anyone? Give it another minute or so? Uh Please do continue filling in the feedback you haven't. Um Someone's asking when surgery is indicated. I'm not sure what they mean. When is surgery? Well, in, in closed injuries. Um, when the Mon Kelly doctrine still applies and the skull is a sealed box. Surgery is indicated if there is a lifethreatening increase in intracranial pressure from an expanding hematoma or from swollen brain with or without hemorrhage. How much there are some operations where you remove part of the brain. If it's very damaged, there are operations where you can open the do a decompressed ectomy, you take part of the skull off, but that's like to be on the scope of this. Talk, to talk about the indications for surgery. I'm assuming I'm talking to the non neurosurgeons for this talk. So I wanted to concentrate on the initial basic management when to refer a patient on for a neurosurgical opinion. Um, doctor, someone is asking if you can share the CT scan indications on screen again if you're able to show your presentation again. Uh, hang on. Um. Mhm. Ok. I got to get back to my screen. Um, I think if you just press on the powerpoint link at the bottom of your screen, it should open up again. Well, I got it here. Yeah. Um, these are standard, standard indications for a CT scan which you can find on the, on the internet. Um Can you see that or is that obscured? Oh, there we are the indications for a CT scan. There you go. Thank you doctor. Um, people are also saying thank you in the chat. So thank you again for. Ok. Well, let me have the feedback in due course. I always need it to see if I've done well or badly. All right, will do hopefully. Um, can I ask there's a few more questions coming in? Ok. All right. Um, someone's asking in post hospital environment. Uh, if after the accident, patient with a closed head injury asks for water, can we give it to him while we the A? Yes, yes, yes. If they're well enough to ask for water, it's very unlikely they're going to need um, an anesthetic. So I think it would be reasonable if they're that. Well, um, and someone was also asking if an intracranial injury is su suspect is suspected. Should the patient be sent to neurosurgery or should the scan be done first? Do the scan first? Well, it depends on how the healthcare system works in your country, but most in your most local hospitals have brain scanners and you do a scan first. Otherwise the neurosurgical department will be swapped in, in head injuries. You do not need neurosurgical treatment. So fewer than probably 5% is a guess, but probably fewer than 5% head injuries actually need, um, referral to a neurosurgical center. Thank you doctor. Um, I think if we don't have any more questions coming in we can end it now. I'll just stop the recording.