Diagnosis &

MANAGEMENT of
HEAD
INJURY
Ayu Lestari

Definition

Head Injury defined as an acute

injury resulting from
mechanical energy to the head
from external physical forces.
Any degree of injury ranging
from scalp laceration to
neurological deficits

Vehicle
acciden
t
Firearm
related
injury

Falls

CAUS
ES
Sports
related
injury

Unknow
n

Assault

Classification
Head
Injury
Anatomi
cal
Findings

Severity

Minimal

Mild

Moderat
e

Severe

Focal

Difuse

anatomical findings
Contusion
Focal

Laceration
Hematoma
Concussion

Diffused

Diffused
Axonal Injury

mechanism

Diagnose
Histor Onset
y
takin Period of loss consciousness
g

Period of post traumatic

amnesia
Period of retrograde amnesia
Presence of headache and
vomitting

Physical Examination
Vital Signs
Laceration or bruising
Scalp laceration, hematoma, depressed fracture

Basal skull fracture sign bone window CT

damage to sigmood sinus : Battles sign

Pettrous pyramid :ottorhoea/ discoloration of tympanic membrane
Pneumochephal,aerocele,rhinorrhoea
racoons eye
Olfactory, facial, & auditory impairment

GCS
Pupil response
Limb weakness

PUPIL RESPONSE
The III nerve function the most useful indicator of
an expanding intracranial lesion.
Herniation of the medial temporal lobe through the
tentorial hiatus damage the III nerve directly or
cause midbrain ischemia pupil dilatation with
impaired or absent reaction to light.
The pupil dilates on the side of the
expanding lesion and is an important
localising sign.
With a further increase in intracranial pressure,
bilateral pupillary dilatation may occur.

Pupil Response

Limb weakness
false localizing sign often seen with
chronic subdural haematomas.
Indentation of the contralateral
cerebral peduncle by the edge of the
tentorium cerebelli (Kernohans notch)
may produce an ipsilateral deficit.
Limb deficits are therefore of limited
value in lesion localization.

Limb weakness

Radio imaging
Immediate CT

Within 8 hours

Glasgow coma score <

15 2 hours from injury
Suspected open or
depressed skull fracture
Sign of basal skull
fracture
Post traumatic seizure
Focal neurological deficit
Anisokor pupil
Hemiparesis
etc
> 1 episode of vomiting

+ age > 65 yo
+ dangerous mechanism
of injury
+bleeding disorder /
anticoagulant

category

GCS

Clinical
findings

CT Scan

minimal

15

LOC (-)PTA (-)

ND(-)

normal

mild

13-15

LOC <10
PTA <1 hour
ND (-)

normal

moderate

9-12

LOC 10 minutes
6 hours
ND (+)
PTA 1 -24 hours

abnormal

Severe

3-8

LOC >6 hours

ND (+)
PTA >24 hours

abnormal

LOC : Loss of Consciousness

PTA : post traumatic amnesia : cannot remember the event of trauma
* differ with retrograde amnesia : cannot remember the event before the trauma
ND : neurological deficit

CT SCAN

Laboratory
CBC
Leukocytosis >14.000 with abnormal CT contusion

Blood glucose

Renal function

Blood gas analysis

Electrolyte

TREAMENT &
MANAGEMENT
Therapy
approach

Consciousn
ess

Surgical
Non surgical

Unconscious
Conscious

Surgical Approach
Closed head injury
Depressed fracture
EDH with hemorrhagic volume 3040 mL or/and midshift > 3 mm
SDH midshift > 3 mm or/and
obliteration or compression of basal
cisterns
Intracerebral hemorrhage that
progressive towards herniation

Open head injury

Open multiple fracture +
dura and brain laceration
Liquourhea more than 14
days
Pneumoenchephaly
Corpus alenium
Gun shot wound

Conscious
Simple head Injury /
minimal
Discharge If Glasgow coma
score = 15

AND
Appropriate supervision at
home
CT not indicated or
Normal imaging head and
spine
All symptoms and signs
resolved

LOSS of Consciousness
Mild (GCS 13-15)
Observe for min.
24 hours on
hospital

Moderate (GCS 913)

ABC
Quick neurological
exam (GCS,
pupillary reflex)
Asses for multiple
injury
Collar for neck
fixation
CT Scan
Monitoring CS

Severe (GCS 3-9)

ABC
Quick neurological exam (GCS, pupillary
reflex)
Asses for multiple injury
Collar for neck fixation
CT Scan

Raised ICP management

Maintain the ICP < 20 mmHg
Head positioning : elevation 20 -30
degrees
Diuretic
Osmotic diuretic (manitol 20%)
dose 0,5-1 g/kg, in 30 minutes
To prevent rebound, re-administration after 6
hours with dose 0,25-0,5/kg n 30 minutes
Maintain the osmolality < 310 mosm
Loop diuretic (furosemid)
Administered with manitol to elongated the
osmotic serum effect of manitol.
Dose: 40 mg/day IV.

Severe head
injury
hypermetaboli
sm up to 2,5
times

Nutriti
on
NGT

Neuroprotec
tor
nimodipine,
citicoline

Nutritional
need raised
40%

Adjuva
nt
therap
y

Steroid
does not
improve
clinical
outcome

Thank you