HEAD INJURY Pt management NEUROLOGY final ppt.pptx

Head injury neurology

1. Submitted by: SIMRAN SHEETAL AKANKSHA

2. DEFINITION : Any degree of injury to the head ranging from scalp lacerations to level of consciousness to focal neurological deficits. Head injury refers to trauma to the head that may result in damage to the scalp, skull, or brain. It can range from mild (concussion) to severe (traumatic brain injury). It’s a damage to the brain caused by an external mechanical force is known as traumatic brain injury (TBI). It may result in temporary or permanent impairments of cognitive, physical, and psychosocial functioning as well as a lowered or altered level of consciousness. INTRODUCTION

3. Head injuries are  one of the most common causes of disability and death in adults . The injury can be as mild as a bump, bruise (contusion), or cut on the head, or can be moderate to severe in nature due to a concussion, deep cut or open wound, fractured skull bone(s), or from internal bleeding and damage to the brain. A head injury is a broad term that describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and blood vessels in the head. Head injuries are also commonly referred to as brain injury, or  traumatic brain injury (TBI) , depending on the extent of the head trauma.

4. Head injury can be traumatic or non-traumatic : ETIOLOGY

5. Relationship with external environment Open head injury Closed head injury According to the GCS scale . Mild head injury Moderate head injury Severe head injury According to the site of injury . Scalp injury Skull injury Brain injury According to the damage . Primary injury Secondary injury CLASSIFICATION

6. Head injury is of two types : Open head injury When the coverings of the brain such as scalp, skull, Meninges are damaged due to any external trauma or force. It's said to be an open head injury. Closed head injury When the brain gets injured without any damage in the covering of the brain with no penetration. It’s said to be a closed head injury. RELATIONSHIP WITH EXTERNAL ENVIRONMENT

7. An open head injury occurs when there is a break in the skull, and the brain's protective covering is breached, exposing the brain to the external environment. In open head injury bleeding is visible. Causes of open head injury Penetrating injuries: Objects, such as bullets or sharp implements, penetrate the skull and enter the brain. Skull fractures with a break in the skin or scalp. Examples of open head injury Gunshot wounds to the head. Stab wounds that penetrate the skull. OPEN HEAD INJURY

8. A closed head injury occurs when there is no open wound in the skull, and the brain remains enclosed within the protective bony structure of the skull. Bleeding is not visible in closed head injury. Ex.- internal bleeding, hemorrhage. Causes: Blunt force trauma: The head collides with an object, but the skull remains intact. Rapid acceleration and deceleration: Sudden stops or changes in direction can cause the brain to move within the skull, leading to injury. Examples: Concussions resulting from a fall or sports-related impact. Contusions (bruising) of the brain tissue due to a blow to the head. CLOSED HEAD INJURY

9. The Glasgow Coma Scale (GCS) is a widely used tool to assess the level of consciousness and neurological status of a person with a head injury. The GCS assigns a score based on the person's responses in three categories: eye opening, verbal response, and motor response. The total GCS score ranges from 3 to 15, with a lower score indicating a more severe impairment of consciousness. The types of head injury based on GCS scores is generally as follows: Severe Head Injury (GCS 3-8): Moderate Head Injury (GCS 9-12): Mild Head Injury (GCS 13-15): ACCORDING TO GLASGOW COMA SCALE

10. Mild head injury is said, when the score of neurological assessment GCS is 13 to 15. Loss of consciousness is only for 15 mins . Individuals with mild head injuries may have minimal symptoms, such as confusion or headache. While these injuries are classified as mild, they still require medical evaluation, as symptoms can sometimes worsen over time. MILD HEAD INJURY

11. Moderate head injury is said, when the score of neurological assessment GCS is 9 to 10 The loss of consciousness is for 6 hours. Individuals with moderate head injuries may be conscious but disoriented, and their neurological status may fluctuate. Medical evaluation and monitoring are crucial to assess for any worsening of symptoms . MODERATE HEAD INJURY

12. Severe head injury is said, when the score of neurological assessment GCS is 3 to 8. The loss of consciousness is for more than 6 hours. GCS 3-8 is often associated with a coma Patients with severe head injuries require immediate medical attention and intensive care. SEVERE HEAD INJURY

13. Head injuries can be classified based on the site or location of the injury. Different regions of the head may be affected, and the classification often helps in understanding the potential impact on the brain. It’s of 3 types : Scalp injury If injury occurs only on the scalp or skin of head and not damage the skull and brain termed as scalp injury. Skull injury If the injury occurs in head and cause fracture or break the bones or skull is termed as skull injury. Brain injury If the injury cause damage in the brain and its structure termed as brain injury which leads to temporary or permanent ACCORDING TO SITE OF INJURY :

14. A scalp injury refers to damage or trauma that occurs to the skin, tissues, or structures covering the top of the head, known as the scalp. Injuries to the scalp can range from minor cuts and bruises to more severe wounds, and they can result from various causes, including accidents, falls, blunt force, or sharp objects. Common types of scalp injuries include: 1. Cuts and Lacerations: 2. Contusions and Bruises: 3. Scalp Abrasions: 4. Scalp Hematomas: 5. Avulsions: 6. Burns: 7. Penetrating Injuries: SCALP INJURY

15. A skull injury refers to any damage or trauma that occurs to the bones of the skull, which encase and protect the brain. The skull is made up of several bones, including the frontal, parietal, temporal, and occipital bones. Skull injuries can vary widely in severity, ranging from minor fractures to more severe traumatic injuries. Types of skull injuries: Skull Fractures: Basilar Skull Fracture: Penetrating Skull Injury: Contrecoup Injury: Intracranial Hemorrhage: Skull Hematoma: Concussion: SKULL INJURY

16. A brain injury, also known as a traumatic brain injury (TBI), occurs when there is damage to the brain caused by an external force. TBIs can result from various incidents, including accidents, falls, sports injuries, assaults, or other traumatic events. The severity of a brain injury can range from mild to severe, and the effects can be temporary or long-lasting. Types of Brain Injuries: Concussion: Contusion: Diffuse Axonal Injury (DAI): Hematoma: BRAIN INJURY

17. Brain injury is of 2 types : Primary head injury  The injury that occurs to the brain immediately or at the time of the trauma is known as primary head injury. Secondary head injury  The injury that occurs to the brain after some time of insult or trauma to the brain is known as secondary brain injury. ACCORDING TO THE DAMAGE:

18. Primary head injury" typically refers to the initial injury that occurs at the site of accident due to impact or trauma to the head. This initial injury can lead to immediate damage to the brain and surrounding structures.  It is of 2 types  Focal brain injury – The injury which occurs at a small specific part of brain is known as focal brain injury. Focal brain injury is further divided into 2 parts: Sharp focal injury Foreign body Depressed skull fracture Blunt focal injury Coup Contrecoup Diffuse brain injury – The injury that occurs and covers the large part of the brain is known as diffuse brain injury. Diffuse brain injury is further divided as: Cerebral contusion Diffuse axonal injury Abusive head trauma/ shaken baby syndrome PRIMARY HEAD INJURY

19. A secondary head injury refers to an injury that occurs because of an initial head injury. It is distinct from the primary injury, which is the initial damage caused by the traumatic event.  Secondary head injuries can develop over time and may be caused by various factors, including physiological changes, complications, or delayed effects of the primary injury. It is of 2 types:  Intracranial head injury – The injury occurs inside the cranial or skull is known as intracranial head injury. Extradural haematoma Subdural haematoma Cerebral oedema Intracranial hypertension 2. Extracranial head injury – The injury outside the cranium or skull is called extracranial head injury SECONDARY HEAD INJURY

20. Altered level of consciousness Pupillary abnormalities (change in shape size and response to light) Altered or absent corneal reflex Sudden onset of neurologic deficits Change in vital signs Sensory dysfunction Vertigo seizures Raised, swollen area from a bump or a bruise  Headache Sensitivity to noise and light Irritability Confusion Jacksonian epilepsy CLINICAL FEATURES

21. dizziness Problems with balance Nausea Problems with memory and/or concentration Change in sleep patterns Alteration in taste Slurred speech Fatigue or lethargy Depressed skull fracture Vascular injuries Facial paralysis (supranuclear) Otorrhea or rhinorrhea Battle’s sign Bilateral periorbital pooling of blood(anterior fossa fracture) Hemi paresis or hemiplegia

22. Complications

23. BRAIN DAMAGE 1.FOCAL INJURY Localized to the area of the brain under the site of impact on the skull.  The damage may be in form of hematoma, edema, contusion, or laceration. 2. DIFFUSE INJURY Classified as  -Diffuse axonal injury  -Cerebral Ischemia  -Cerebral Swelling

24. FOCAL DAMAGE Most common sites involves the frontal and temporal lobes. It includes Hematoma --"Localized bleeding outside the blood vessels due to trauma or injury and may involve blood leaking.  Edema -- "Swelling in the brain due to accumulation of fluid like CSF or blood" Contusions --"It is an injury to the tissue in which blood capillaries are ruptured and causes bruise" Laceration -- "It is the cutting of brain tissues"

25. TYPES OF FOCAL DAMAGE

26. 1. CORTICAL CONTUSION AND LACERATIONS These may occur due to  countre  coup.  Contre coup injury is caused when the brain bounces off the surface and impacts against the opposite side of the skull. Contusions can be multiple and bilateral. Multiple contusions doesn’t lead to unconsciousness but when bleeding arises and leads to hematoma in the contusions there can be chances of patient going unconscious. A concussion refers to more widespread brain trauma from a blow to the head, there is no structural damage to brain tissue.

27. Cerebral lacerations are tears in brain tissue caused by a foreign object or pushed in bone fragment from skull fracture. Contusion is any injury that causes blood to collect under the skin. Because the blood must clot to stop the bleeding a bruise results from, contusions also increase cardiovascular risks.

28. INTRACRANIAL HAEMATOMA It is the collection of blood within the skull. It leads to headache, vomiting, dizziness, confusion. It is divided into two types -- Extradural & Intradural

29. EXTRADURAL HEMATOMA Collection of blood that forms between the skull and outer layer of dura which is called the endosteal layer. INTRADURAL HEMATOMA Collection of blood within the dura.  Consists of mixture of subdural and intra cerebral hematoma

30. Intra dural Hematoma Subdural Hematoma  Blood is leaked into a space below the dura matter  Symptoms—Vomiting, Nausea, Confusion Intra Cerebral Hematoma  It occurs when there is leak in the cerebrum. Intra Cerebral + Subdural Hematoma [Burst Lobe]  Frontal and Temporal Lobes may lead to brain surface. Burst lobe is .said because the appearance of intra cerebral hematoma is mixed .with the necrotic brain tissue rupturing out into the subdural space.

31. 2. HERNIATION It is the movement of brain tissue from one intra cranial compartments to another.  It is of three types: i )Lateral tentorial herniation— Tentorium is the layer which is present between the two layers of the dura mater. The tentorium has sinuses which carries the impure blood. It is the herniation of temporal lobe. ii)Central tentorial herniation—Uncontrolled lateral tentorial herniation. iii)Tonsillar herniation—Herniation of cerebellar tonsils. Cerebellar tonsils  helps in the movement of distal parts of the limbs

32. 3. INFECTION Infection occurs in the brain when there is a fracture which leads to dural tear. This occurs within 48 hours of injury.  Meningitis may develop after several months or years.  It is the infection and inflammation of meninges. Typically trigger symptoms like fever, stiff neck. Infection in brain can further lead to cerebral abscess. It is a puss filled pocket of infected material in brain.

33. DIFFUSE DAMAGE Diffuse Damage of the brain refers to the widespread injury or trauma that affects multiple area of the brain. It includes  (A) Diffuse axonal injury  (B) Cerebral Ischemia  (C)Cerebral Swelling (D) Increase intra cranial pressure

34. A.DIFFUSE AXONAL INJURY It is characterized by tearing and damaging of axons. Occurs due to acceleration and rotational forces. After 48 hours further damage results from release of excitotoxic neurotransmitters which is glutamate which is responsible for release of calcium, which causes calcium influx. It leads to formation of blood clot and necrosis ( cell death).  Depending on the severity of the injury effects  may range from mild to death. On testing, retraction balls can be seen or microglial cluster

35. B. CEREBRAL ISCHEMIA Commonly occurs after severe head injury and is caused by hypoxia or impaired cerebral perfusion. Cerebral perfusion refers to the blood flow that supplies oxygen to the cerebral tissues, if it reduced it leads to cerebral ischemia

36. (C)  Cerebral Swelling Occurs when there is abnormal increase in size of the brain due to edema or vasodilation (widening of blood vessels). (D)  Increase intra cranial pressure Pressure exerted by the cranium on the brain tissues, cerebrospinal fluid and the brains circulating blood volume. Due to swelling or abnormality there is increase in ICP levels. Elevated ICP can lead to hematoma Normal ICP—4 to 15mmHg and severe ICP can lead to herniation and death.

37. E. CEREBROSPINAL FLUID Cerebrospinal fluid can leak from the brain due to certain conditions, injuries or surgeries. CSF is a clear fluid that surrounds and protects brain and spinal cord. It can also be caused due to tear in dura mater and weakness in bone, it can increase the risk of infections.

38. CLINICAL ASSESSMENT EXAMINATION Evidence of injury (Lacerations and bruising) : The presence of these features confirms the occurrence of a head injury, but traumatic intracranial hematoma can occur in patients with no external evidence of injury. Basal Skull Fracture : The existence of a basal skull fracture, which may be difficult to spot on a skull X-ray or CT scan. If there is, there is a chance of infection and along with it the risk of meningitis. 

39. Anterior Fossa Fracture Rhinorrhoea : CSF leak from nose.  Bilateral periorbital:   Pooling of blood surrounding the eyes Petrous Fracture Otorrhea: CSF leak from ear. Battle's sign: Bruising over the mastoid .

40. Conscious Level – Glasgow Coma Score(GCS) Glasgow coma score

41.   Pupil size and response - Herniation of the medial temporal lobe through the tentorial hiatus may damage the III nerve directly or cause midbrain ischemia, resulting in pupil dilatation. The pupil dilates on the side of the expanding lesion  and is an important localizing sign as it is the most useful indicator of an expanding intracranial lesion. With a further increase in intracranial pressure, bilateral pupillary dilatation may occur. Signs of skull fracture Bilateral periorbital edema (raccoon eyes) Battle’s sign (bruising over mastoid) Cerebrospinal fluid rhinorrhoea or otorrhoea Haemotympanum or bleeding from ear Full neurological examination: tone, power, sensation, reflexes

42. Limb Weakness : Hemiparesis or hemiplegia usually occurs in the limbs contralateral or same side of the lesion.  Kernohan notch phenomenon is an imaging finding resulting from extensive midline shift due to mass effect, resulting in the indentation of the contralateral cerebral crus by the tentorium cerebelli. This has also been referred to as the  Kernohan-Woltman notch phenomenon and is a false localizing sign. Eye Movements : Abnormal eye movements may result from: brain stem dysfunction, damage to the nerves supplying extraocular muscles or damage to the vestibular apparatus.  

43. CT Scan      - presence of hematoma      - contusion                                                                    - swelling MRI Scan ICP monitoring Electroencephalography Transcranial Doppler X-RAY - suspected penetrating injuries      - scalp bruising INVESTIGATIONS

44. Management Management aims at preventing the development of secondary brain damage from intracranial hematoma, ischemia, raised intracranial pressure with tentorial or tonsillar herniation and infection. TO prevent S ECONDARY BRAIN INJURY (especially from hypotension and hypoxia) • Maintain systolic blood pressure >90mmHg • PaO2<60mmHgand O2saturation <90%should be avoided. • Monitor blood glucose • Monitor temperature • Prevent occurrence or recurrent early post- traumatic seizures TO CONTROL INTRACRANIAL PRESSURE : • Nurse in 30o head up position (head of bed) • Ensure cervical spine immobilisation device does not obstruct jugular venous flow • ICP Monitors: – for patients with GCS <8, – Patients with abnormal cranial CT findings – Post operative patients. • Initiate treatment of ICP when >20mmHg  

45.   CSF DRAINAGE-  External ventricular drain, ventriculostomy • Sedation and pharmacologic paralysis – Using barbiturates • Use of mannitol and other diuretic agents – 0.25- 1g/kg every 4-6 hours (monitor serum osmolality- 320mOsm/kg) • Hyperventilation to PaCo2 of 30-35mmHg (cranial vasoconstriction) • Decompressive craniectomy SURGICAL MANAGEMENT Evacuation via Burr-hole opening into cranium with a drill Craniotomy : bone flap temporarily removed from skull to access brain Craniectomy : skull flap is removed but not replaced immediately Cranioplasty : surgical repair of defect of deformity of s

46. REHABLITATION Ambulatory and Home Care • Nutrition • Bowel and bladder management • Family participation and education • Physiotherapy

47. PT management Determined by the state of the patient. Patient level of consciousness, alertness and ability to comprehend as well as learn taught skills. For practical purposes patient are classified into two category for treatment purposes as 1. Patient who are totally unconscious and 2. Patient who have regained their consciousness.

48. Management of Unconscious Patients Treatment comprises of passive maneuvers that are necessary to maintain certain functions in the patient to prevent secondary problems. Respiratory Care – the need for chest care is directly proportional to the extent of unconsciousness. Generally chest physiotherapy is given every 4 to 5 hourly. This is necessary to maintain good bronchial hygiene. Proper positioning of the patient associated with regular suctioning and nebulization enable the patient to have a relative clear lung. Head low position should never be given to the head injury patient as it may cause a severe increase in the intracranial pressure that may prove to be hazardous. 2. Preventing Contractures and Deformity 3. Prevention and Treatment of Pressure Sores 4. Sensory Stimulation Management of Unconscious Patients

49. 2. Preventing Contractures and Deformity Passive movements should be given to the patient for all the joints including all the movements at that particular joint. Each movement may be repeated at least 8 to 12 times. Passive movements should be given every 3 to 4 hours . Gentle rhythmic stretching is very essential especially for bi -articular muscles as they become very prone to develop tightness. Use of appropriate splints and proper positioning is also desirable to prevent the chances of the patient developing any contracture. The patient should be kept clean.  The cloths should be regularly changed. Moisture increases the changes of skin infection and at the same time dry skin cause easy breakdown hence the patient's skin should be maintained in correct manner.

50. 3. Prevention and Treatment of Pressure Sores The chances of sores can be kept to the minimum by taking certain preventive measures. The patient position should be changed from supine to side lying on either sides every 2 hourly at least. This will cause vascularization of almost all the areas of the body. Prevention and Treatment of Pressure Sores The patient should be made to lie on water bed or air bed which helps in evenly distributing the weight throughout the body thus relieving some pressure from the above mentioned areas. Regular massage of pressure prone areas helps in increasing the circulation of these areas hence preventing pressure sores.  Regular sponge bath helps in maintaining proper hygienic condition of the patients skin which offers resistance to development of unwanted infection.  In case the patient develops pressure sore then its healing can be accelerated by giving  ozone therapy,  UVR, IR or direct current.  Ice massage given at the edges of the sores  Sterile dressing should be applied following these physical therapy modalities.

51. 4. Sensory Stimulation Auditory Tactile  Proprioceptive stimulation Sensory Stimulation

52. Management of conscious patient In patients who is conscious, active participation of the patient should be encouraged which in turn will speed up the rehabilitation process. 1. Improve Alertness or Arousal through Sensory Stimulation 2. Prevention of Spasticity 3. Maximize the Patient’s Functional Capacity 4. Development of High Level Skillful Functioning

53. 1. The main aim is to stimulate the reticular activating system by making the patient sit or even stand in the tilt table.  The therapist should provide tactile, visual, auditory and proprioceptive stimulation to the patient that will send facilitator signals to the brain and will enable the alert response to be provoked.  Auditory stimulation can be given by speaking to the patient during the course of treatment. Improve Alertness or Arousal through Sensory Stimulation Visual stimulation is given by showing familiar faces, objects or movement in the visual field of the patient. Tactile stimulation is provided by the therapist’s touch for carrying out various functional tasks. The touch of the patient also stimulates the receptors in the muscles and can be used for facilitating or inhibiting contraction of muscles. Improve Alertness or Arousal through Sensory Stimulation Proprioceptive stimulation by giving traction and approximation at joint structures is very helpful in stimulating the arousal response in the patient.

54. Prevention of Spasticity Gentle passive movement, gradual rhythmic sustained stretch, prolonged icing for 20 minutes over the muscles, biofeedback, proper positioning

55. Maximize the Patient’s Functional Capacity  The main aim of this management is to  improve the ROM,  improve the control of voluntary movement,  strengthening paretic muscles,  improve the coordination,  balance and teach various safety measures which will enable the patient to return back to the community.  Neuromuscular training activities like  bridging,  prone on elbow,  side lying to sitting,  sitting,  kneeling,  half kneeling,  standing and  walking.  Proper documentation Use of vestibular ball while training the patient for crawling, bridging, sitting balance helps in building the proprioceptive stimulation and teaches proper control to the patient.  Each task has various sub tasks which needs to be mastered by the patient so that he learns the actual activity using normal movement combination and performs it with precision.  Repetition of activities  Ambulation training should always be done in upright position by training the patient in each and every phase of the gait cycle. If the patient’s balance is poor then assistance may be used.

56. Development of High Level Skillful Functioning These achievements may not be applicable to all head injury .Patient belonging to the last two grades of cognitive grading may be considered as appropriate client for this training.  The safety awareness of the patient need to be improved because he is already in ambulatory stage.  Balance and postural control training is very essential. Some patients may have good balance and postural control during normal walking but will have problems while trying to perform speedy actions. Dancing, basket ball, karate, tennis and certain other sports often promote additional progress in balance, sequencing, and speed of movement. The therapist should encourage those components of the activities that best address the deficits in the patient and plan out enjoyable activities that provide specific training for the deficits in balance, gait, upper extremity functions.