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Head Trauma

Head trauma occurs when external forces are directed to the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy and brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification structures, resulting in damage to the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy, brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification, and intracranial structures. Head injuries can be classified as open (penetrating) or closed (blunt), and primary (from the initial trauma) or secondary (indirect brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification injury), and range from mild to severe and life-threatening. The majority of cases are mild, but presentation can vary from a mild concussion to a comatose Comatose A profound state of unconsciousness associated with depressed cerebral activity from which the individual cannot be aroused. Coma generally occurs when there is dysfunction or injury involving both cerebral hemispheres or the brain stem reticular formation. Hyponatremia state depending on the severity of the insult. Management ranges from observation to intensive care monitoring and neurosurgical interventions. Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is good for mild injuries, but severe trauma can result in death or permanent damage.

Last updated: Sep 16, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Head trauma is an injury to the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy, brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification, and/or intracranial structures.

Epidemiology

  • 2.8 million people suffer head injuries each year in the United States.
  • 75% of cases are considered mild.
  • The most common injury resulting in death
  • Bimodal age distribution, with children, young adults, and the elderly having a higher incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency
  • More common in men than women

Etiology

Classification of Severity

Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale Scale Dermatologic Examination ( GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma)

  • The GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma exam addresses the level of consciousness after a head injury.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship receive a score for the best response in each area.
  • Scores in each area are combined to reach a total score of 3–15.
  • ↑ the number → the better the prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas
  • Score ≤ 9:
Table: Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale Scale Dermatologic Examination
Feature Response Score
Eye opening Open spontaneously 4
Open to verbal command 3
Open to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways 2
No eye opening 1
Verbal response Oriented and appropriate 5
Disoriented but conversant 4
Nonsensical words 3
Moaning 2
Silent 1
Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology response Follows commands 6
Localizes pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways 5
Withdraws from pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways 4
Flexor posturing 3
Extensor posturing Extensor posturing A condition characterized by abnormal posturing of the limbs that is associated with injury to the brainstem. This may occur as a clinical manifestation or induced experimentally in animals. The extensor reflexes are exaggerated leading to rigid extension of the limbs accompanied by hyperreflexia and opisthotonus. This condition is usually caused by lesions which occur in the region of the brainstem that lies between the red nuclei and the vestibular nuclei. In contrast, decorticate rigidity is characterized by flexion of the elbows and wrists with extension of the legs and feet. The causative lesion for this condition is located above the red nuclei and usually consists of diffuse cerebral damage. Increased Intracranial Pressure (ICP) 2
Flaccid 1

Traumatic brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification injury (TBI) severity scale Scale Dermatologic Examination

  • Mild TBI:
    • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma of 13–15
    • Non-severe mechanism
    • 0–30-minute loss of consciousness
    • Amnesia brief, < 24 hours
  • Moderate TBI:
    • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma of 9–12
    • Loss of consciousness for > 30 minutes and < 24 hours
    • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
    • Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
    • Amnesia > 24 hours and < 7 days
    • Alteration in mental status at the time of injury
  • Severe TBI:
    • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 9
    • Prolonged loss of consciousness (> 24 hours)
    • Neurologic deficits Neurologic Deficits High-Risk Headaches
    • Amnesia > 7 days 
Table: Classification of TBI severity
Criteria Mild Moderate Severe
Structural imaging Normal Normal or abnormal Normal or abnormal
LOC 0–30 minutes > 30 minutes and < 24 hours > 24 hours
AOC For a moment, up to 24 hours > 24 hours severity based on other criteria
PTA PTA A peritonsillar abscess (PTA), also called quinsy, is a collection of pus between the capsule of the palatine tonsil and the pharyngeal muscles. A pta is usually a complication of acute tonsillitis, an infection caused by group a streptococci. Patients often present with a sore throat, trismus, and a muffled voice. Peritonsillar Abscess 0–1 day > 1 and < 7 days > 7 days
GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma 13–15 9–12 < 9
LOC: loss of consciousness
AOC: alteration of consciousness/mental state
PTA PTA A peritonsillar abscess (PTA), also called quinsy, is a collection of pus between the capsule of the palatine tonsil and the pharyngeal muscles. A pta is usually a complication of acute tonsillitis, an infection caused by group a streptococci. Patients often present with a sore throat, trismus, and a muffled voice. Peritonsillar Abscess: post-traumatic amnesia
GSC: Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale Scale Dermatologic Examination (best available score in the first 24 hours)

Pathophysiology

Timing

  • Primary:
    • Occurs at the moment of injury
    • Coup (on the side of impact) and contrecoup (on opposite side) injuries
    • Acceleration-deceleration injuries (abrupt brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification movement and deformation within cranial cavity; common in motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle collisions)
  • Secondary: 
    • Injuries that occur hours/days/weeks after trauma
    • Result from the body’s response to the original trauma
    • Molecular injury mechanisms ( inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, apoptosis Apoptosis A regulated cell death mechanism characterized by distinctive morphologic changes in the nucleus and cytoplasm, including the endonucleolytic cleavage of genomic DNA, at regularly spaced, internucleosomal sites, I.e., DNA fragmentation. It is genetically-programmed and serves as a balance to mitosis in regulating the size of animal tissues and in mediating pathologic processes associated with tumor growth. Ischemic Cell Damage, secondary ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage)
    • Can result in local or diffuse brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, hemorrhage or ↑ intracranial pressure Intracranial Pressure Idiopathic Intracranial Hypertension ( ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)), electrolyte disturbance
    • May eventually lead to coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma and death

Types

  • Open (penetrating):
    • Injury that involves penetration Penetration X-rays of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy, dura mater Dura mater The outermost of the three meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord. Meninges: Anatomy, and fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the calvarium Calvarium Skull: Anatomy
    • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tissue is directly injured by fragments of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types or other objects such as bullets, knives, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).
  • Closed:
    • More common than open injuries
    • Intact cranium Cranium The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy and dura mater Dura mater The outermost of the three meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord. Meninges: Anatomy
    • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification is damaged due to acceleration-deceleration.
    • Can be focal or diffuse
Coup and contrecoup head injury

Coup and contrecoup head injury

Image: “Contrecoup” by Patrick J. Lynch. License: CC BY 2.5

Types of Injuries

Skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures

  • Occur when mechanical force exceeds the integrity of calvarium Calvarium Skull: Anatomy
  • Often associated with intra- and extracranial injuries
  • Parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is most commonly fractured.

Linear fractures:

  • Most common skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures
  • Patient presents with swelling Swelling Inflammation overlying the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures site.
  • Neurologic symptoms or intracranial hemorrhage Intracranial hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most sahs originate from a saccular aneurysm in the circle of willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage are rare.
  • Usually, no intervention is needed.

Comminuted fractures:

  • Complex, with multiple bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragments
  • Associated with a significant force of impact
  • Often become depressed fractures

Depressed fractures:

  • Significant force results in inward displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of a portion of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy.
  • May be closed or open (with skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma)
  • May be seen on exam as obvious depressed area
  • Can lacerate dura mater Dura mater The outermost of the three meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord. Meninges: Anatomy, create a point of entry into the cerebrospinal fluid Cerebrospinal Fluid A watery fluid that is continuously produced in the choroid plexus and circulates around the surface of the brain; spinal cord; and in the cerebral ventricles. Ventricular System: Anatomy, and introduce infection
  • Clinical presentation depends on underlying brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification injury.

Elevated fractures:

  • Elevation of a bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragment above calvarium Calvarium Skull: Anatomy
  • Rare, usually involve frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy bones
  • Associated with tangential impact
  • Usually have significant underlying brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification injury

Basilar skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures:

  • Include fractures of:
    • Cribriform plate of the ethmoid bone Ethmoid bone A light and spongy (pneumatized) bone that lies between the orbital part of frontal bone and the anterior of sphenoid bone. Ethmoid bone separates the orbit from the ethmoid sinus. It consists of a horizontal plate, a perpendicular plate, and two lateral labyrinths. Orbit and Extraocular Muscles: Anatomy
    • Orbital plate of the frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
    • Temporal bone Temporal bone Either of a pair of compound bones forming the lateral (left and right) surfaces and base of the skull which contains the organs of hearing. It is a large bone formed by the fusion of parts: the squamous (the flattened anterior-superior part), the tympanic (the curved anterior-inferior part), the mastoid (the irregular posterior portion), and the petrous (the part at the base of the skull). Jaw and Temporomandibular Joint: Anatomy
    • Sphenoid bone Sphenoid bone An irregular unpaired bone situated at the skull base and wedged between the frontal, temporal, and occipital bones (frontal bone; temporal bone; occipital bone). Sphenoid bone consists of a median body and three pairs of processes resembling a bat with spread wings. The body is hollowed out in its inferior to form two large cavities (sphenoid sinus). Orbit and Extraocular Muscles: Anatomy
    • Occipital Occipital Part of the back and base of the cranium that encloses the foramen magnum. Skull: Anatomy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
  • Most common through a temporal bone Temporal bone Either of a pair of compound bones forming the lateral (left and right) surfaces and base of the skull which contains the organs of hearing. It is a large bone formed by the fusion of parts: the squamous (the flattened anterior-superior part), the tympanic (the curved anterior-inferior part), the mastoid (the irregular posterior portion), and the petrous (the part at the base of the skull). Jaw and Temporomandibular Joint: Anatomy
  • Epidural hematomas common (injury to middle meningeal artery Middle Meningeal Artery Epidural Hemorrhage and vein)
  • Presentation depends on the degree of brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification, cranial nerves Cranial nerves There are 12 pairs of cranial nerves (CNs), which run from the brain to various parts of the head, neck, and trunk. The CNs can be sensory or motor or both. The CNs are named and numbered in Roman numerals according to their location, from the front to the back of the brain. The 12 Cranial Nerves: Overview and Functions, and vessels injury:
    • Rhinorrhea Rhinorrhea Excess nasal drainage. Respiratory Syncytial Virus or otorrhea Otorrhea Otitis Externa ( cerebrospinal fluid Cerebrospinal Fluid A watery fluid that is continuously produced in the choroid plexus and circulates around the surface of the brain; spinal cord; and in the cerebral ventricles. Ventricular System: Anatomy (CSF) leak)
    • Hemotympanum (blood behind tympanic membrane Tympanic membrane An oval semitransparent membrane separating the external ear canal from the tympanic cavity. It contains three layers: the skin of the external ear canal; the core of radially and circularly arranged collagen fibers; and the mucosa of the middle ear. Ear: Anatomy)
    • Raccoon eyes Raccoon Eyes Le Fort Fractures ( periorbital Periorbital Orbital and Preseptal Cellulitis ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures)
    • Battle sign (retroauricular or mastoid ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures)
    • Subconjunctival hemorrhage
    • Nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics and vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
    • Cranial nerve palsies Cranial Nerve Palsies Cranial nerve palsy is a congenital or acquired dysfunction of 1 or more cranial nerves that will, in turn, lead to focal neurologic abnormalities in movement or autonomic dysfunction of its territory. Head/neck trauma, mass effect, infectious processes, and ischemia/infarction are among the many etiologies for these dysfunctions. Diagnosis is initially clinical and supported by diagnostic aids. Management includes both symptomatic measures and interventions aimed at correcting the underlying cause. Cranial Nerve Palsies 

Intracranial bleeding

Focal cerebral contusions:

  • Most common hemorrhagic lesions
  • Usually in basal frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy and temporal regions
  • Disruption of intraparenchymal vessels may lead to larger intracerebral hematomas.

Extra-axial hemorrhage:

  • Epidural hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception:
    • Results from rupture of the middle meningeal artery Middle Meningeal Artery Epidural Hemorrhage
    • Life-threatening condition 
    • Rapidly expanding blood collection in the potential space between the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy and dura mater Dura mater The outermost of the three meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord. Meninges: Anatomy 
    • Initial loss of consciousness marked by lucid interval Lucid Interval Epidural Hemorrhage (temporary neurological recovery)
    • Computed tomography (CT) scan shows biconvex, hyperdense blood collection that does not cross the suture lines.
    • Usually requires emergent surgery
  • Subdural hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception:
    • Blood collection between the dura and the arachnoid membrane due to rupture of bridging veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology
    • CT scan shows crescent-shaped blood collection that crosses the suture lines.
  • Subarachnoid hemorrhage:
    • Results from tear of small pial vessels
    • Usually in sylvian fissures and interpeduncular cisterns
    • Can extend into intraventricular hemorrhage Intraventricular hemorrhage Bleeding within the cerebral ventricles. It is associated with intraventricular trauma, aneurysm, vascular malformations, hypertension and in very low birth weight infants. Intracerebral Hemorrhage

Diffuse axonal injury (DAI)

  • Associated with acceleration-deceleration injury with unrestricted head movement 
  • Rotational forces affect the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification areas with different density (gray-white matter junction).
  • Symptoms can be mild, but typically are severe. 
  • Severe DAI patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship have loss of consciousness, which persists to a vegetative state (90% of cases).
  • CT scan or magnetic resonance imaging (MRI) shows numerous minute punctate hemorrhages with blurring of grey-white interface.
  • Most significant cause of morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with TBIs as it results in vegetative state 

Concussion

  • Mild TBI
  • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma score 13–15
  • Usually no visible abnormalities on CT scan
  • Believed to be a functional rather than anatomic disturbance
  • Results from mild cortical contusions on coup or contrecoup sides
  • Mild axonal injury
  • Early symptoms of concussion include:
    • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
    • Dizziness Dizziness An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. Lateral Medullary Syndrome (Wallenberg Syndrome) 
    • Disorientation Disorientation St. Louis Encephalitis Virus
    • Amnesia for the traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD)
    • Nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics and vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
  • Post-concussion syndrome:
    • Symptoms persist weeks to months after injury.
    • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, dizziness Dizziness An imprecise term which may refer to a sense of spatial disorientation, motion of the environment, or lightheadedness. Lateral Medullary Syndrome (Wallenberg Syndrome), cognitive impairment, and psychological symptoms
    • May be a result of secondary injury:
      • Release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of excitatory neurotransmitters
      • Generation of free radicals Free radicals Highly reactive molecules with an unsatisfied electron valence pair. Free radicals are produced in both normal and pathological processes. They are proven or suspected agents of tissue damage in a wide variety of circumstances including radiation, damage from environment chemicals, and aging. Natural and pharmacological prevention of free radical damage is being actively investigated. Ischemic Cell Damage

Diagnosis

History and physical exam

  • Reported loss of consciousness and for how long
  • Mental status ( GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma evaluation)
  • Scalp lacerations, palpable fractures
  • Signs of basilar skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures:
  • Neurologic exam

Canadian CT Head Rule (CCHR)

The CCHR is used to determine the need for CT in adult emergency department patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with minor head injuries. Its sensitivity is close to 100% for identifying clinically significant brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification trauma (i.e., trauma that requires neurosurgical intervention).

Requirements:

  • None of the exclusion criteria are met MET Preoperative Care.
  • At least 1 of the inclusion criteria is present.

Inclusion criteria:

  • Loss of consciousness
  • Amnesia to the head injury event
  • Witnessed disorientation Disorientation St. Louis Encephalitis Virus
  • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma 13–15

Exclusion criteria:

  • Age < 16 years
  • Blood thinners
  • Seizure after injury

High-risk factors:

  • GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 15 2 hours post-injury
  • Suspected open skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Sign of base of skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia more than twice
  • Age > 65 years

​Medium risk factors:

  • Amnesia post-event > 30 minutes
  • Dangerous mechanism of injury
  • Pedestrian struck by motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle
  • Occupant ejected from motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle
  • Fall from > 3 feet (1 meter) or down 5 stairs

Interpretation:

  • If no risk factors, CT of the head is unnecessary.
  • If any of the above risk factors are identified, a CT of the head should be obtained.

Imaging

  • CT scan without contrast (1st line):
    • Skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures
    • Dura mater Dura mater The outermost of the three meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord. Meninges: Anatomy injury
    • Midline shift 
    • Bleeding (epidural, subdural, subarachnoid, intracerebral)
    • Diffuse axonal injury (DAI) 
  • CT angiography CT angiography A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Imaging of the Lungs and Pleura: if vascular injury is suspected
  • MRI: 
    • For late diagnosis (> 48 hours after trauma) 
    • Can evaluate for contusion and concussion better than CT 

Management

Initial management

  • Airway Airway ABCDE Assessment protection: intubation Intubation Peritonsillar Abscess usually required for GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 9
  • Fluid resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome, oxygenation
  • Assessment and management of associated injuries
  • Antifibrinolytic therapy:
    • For moderate TBI ( GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma 9–12)
    • Within 3 hours of injury
    • Reduces mortality Mortality All deaths reported in a given population. Measures of Health Status

Concussion (mild TBI)

  • No specific treatment
  • Observation for 4–6 hours or CT scan without contrast
  • Avoid narcotics or anything that could alter the patient’s mental status.
  • Control pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with over-the-counter medicines such as acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen or ibuprofen Ibuprofen A nonsteroidal anti-inflammatory agent with analgesic properties used in the treatment of rheumatism and arthritis. Nonsteroidal Antiinflammatory Drugs (NSAIDs).
  • Athletes should abstain from contact sports until cleared by a medical provider.

Moderate or severe TBI

Intensive care management (typically required):

  • Maintain euvolemia Euvolemia Volume Depletion and Dehydration ( isotonic Isotonic Solutions having the same osmotic pressure as blood serum, or another solution with which they are compared. Renal Sodium and Water Regulation intravenous fluids Intravenous Fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids).
  • Maintain cerebral perfusion Cerebral Perfusion Syncope pressure:
    • Avoid hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension.
    • Monitor ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP) (if GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 9 or evidence of hemorrhage).
  • Mechanical ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing
  • Correct coagulopathy
  • Maintain optimal body temperature Body Temperature The measure of the level of heat of a human or animal. Heatstroke and glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance levels
  • Seizure prophylaxis Prophylaxis Cephalosporins

Control of ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP):

  • Head elevation
  • Hyperventilation Hyperventilation A pulmonary ventilation rate faster than is metabolically necessary for the exchange of gases. It is the result of an increased frequency of breathing, an increased tidal volume, or a combination of both. It causes an excess intake of oxygen and the blowing off of carbon dioxide. Respiratory Alkalosis
  • Sedation and analgesia Analgesia Methods of pain relief that may be used with or in place of analgesics. Anesthesiology: History and Basic Concepts
  • CSF drainage: through ventriculostomy Ventriculostomy Surgical creation of an opening in a cerebral ventricle. Neurosurgery
  • Osmotic therapy:
    • Hypertonic Hypertonic Solutions that have a greater osmotic pressure than a reference solution such as blood, plasma, or interstitial fluid. Renal Sodium and Water Regulation saline
    • Mannitol Mannitol A diuretic and renal diagnostic aid related to sorbitol. It has little significant energy value as it is largely eliminated from the body before any metabolism can take place. It can be used to treat oliguria associated with kidney failure or other manifestations of inadequate renal function and has been used for determination of glomerular filtration rate. Mannitol is also commonly used as a research tool in cell biological studies, usually to control osmolarity. Osmotic Diuretics

Surgery:

  • Decompressive craniectomy Decompressive Craniectomy Excision of part of the skull. This procedure is used to treat elevated intracranial pressure that is unresponsive to conventional treatment. Neurosurgery for refractory ICP ICP Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP) elevation
  • Evacuation of hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception:
    • Epidural: if > 30 cc of blood
    • Subdural: if > 10 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma or > 5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma midline shift on CT
    • Intracerebral: if significant mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast effect
  • Closure of dura, debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome, elevation:
    • For depressed skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy fractures
    • For penetrating injuries Penetrating injuries Wounds caused by objects penetrating the skin. Genitourinary Trauma

References

  1. Ian Stiell. Canadian CT Head Injury/Trauma Rule. Retrieved January 12, 2021, from https://www.mdcalc.com/canadian-ct-head-injury-trauma-rule
  2. Evans, R. (2018). Postconcussion syndrome. UpToDate. Retrieved January 12, 2021, from https://www.uptodate.com/contents/postconcussion-syndrome
  3. Evans R.W., Whitlow C.T. (2019). Acute mild traumatic brain injury (concussion) in adults. UpToDate. Retrieved January 12, 2021, from https://www.uptodate.com/contents/acute-mild-traumatic-brain-injury-concussion-in-adults
  4. Healy, Ellen & Walter, Kristen & Chard, Kathleen. (2015). Effectiveness of Cognitive Processing Therapy for PTSD Across Various Populations, Traumatic Events, and Co-occurring Conditions. https://doi.org/10.1007/978-3-319-08613-2_114-1 
  5. Heegard W. (2019). Skull fractures in adults. UpToDate. Retrieved January 12, 2021, from https://www.uptodate.com/contents/skull-fractures-in-adults
  6. Rajajee, V. (2019). Management of acute moderate and severe traumatic brain injury. UpToDate. Retrieved January 12, 2021, from https://www.uptodate.com/contents/management-of-acute-moderate-and-severe-traumatic-brain-injury
  7. Rajajee, V. (2020). Traumatic brain injury: Epidemiology, classification, and pathophysiology. UpToDate. Retrieved December 24, 2020, from https://www.uptodate.com/contents/traumatic-brain-injury-epidemiology-classification-and-pathophysiology#H4 

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