General Surgery
Mosul university- College of dentistry-oral & maxillofacial surgery departmentDr. Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)
Head injury
Anatomy
Mosul university- College of dentistry-oral & maxillofacial surgery departmentAnatomy
Mosul university- College of dentistry-oral & maxillofacial surgery departmentHead injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentis any alteration in mental or physical functioning related to a blow to the head, lead to complex pathophysiological process affecting the brain, Loss of consciousness does not need to occur.
Classification of head injury: 1- primary HI. Related to trauma 2- secondary HI. Related to other causes.
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentImportant as it involves young people & associated with high mortality & morbidity & development of many neurologic deficit & their sequel.Most common causes is FFH, FOG, RTA, BI, Sport injury, fighting, strike by object,……. Mechanism: Direct force, shearing force.
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentTypes of head injury
Mosul university- College of dentistry-oral & maxillofacial surgery department1- scalp injury. 2- scalp & skull fracture. 3- scalp & skull fracture & meninges. 4- scalp & skull fracture & meninges & brain contusion or laceration
Scalp injury
Mosul university- College of dentistry-oral & maxillofacial surgery departmentScalp injury
Mosul university- College of dentistry-oral & maxillofacial surgery departmentScalp injury: Simple lacerations debridement & suture. Galea 3\0 resorbable suture & skin by 3\0 nylon or staples Subgaleal heamatoma conservative treatment Scalp loss , intact periostium & skull split thickness grafts Destroyed periostium & skull fracture, local or distant flaps. Microvascular reattachment
Skull fracture
Mosul university- College of dentistry-oral & maxillofacial surgery department1- linear non-depressed fractures 2- depressed skull fractures 3- open skull fractures 4- base of skull fractures
Skull fracture
DepressedLinear
Stellate
Basilar
Skull Fractures
Mosul university- College of dentistry-oral & maxillofacial surgery department
Brain injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentDiffused brain injury A- concussion B- diffuse axonal injury DAI Focal injuries A- contusion B- intracranial haemorrhages --meningeal haemorrhages 1- extradural haemorrhage 2- subdural haemorrhage 3- subarachnoid haemorrhage --brain haemorrhage & lacerations 1- intracerebral hematoma 2- impalement injuries 3- bullet wounds
Assessment of H.I.
Mosul university- College of dentistry-oral & maxillofacial surgery departmentHistoryType of injuryVital signs (BP ↑ with bradycardia slow RR)Initial neurological examination1- level of consciousness (GCS)2- examination of the eye movement3- examination of the motor system4- examination of the cranial nerves
Glasgow Coma Scale
Mosul university- College of dentistry-oral & maxillofacial surgery department
Motor
Verbal
Obeys 6 Localizes 5 Withdraws 4 Flexion 3 Extends 2 None 1
Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1
Eye Opening
Spontaneous 4 To speech 3 To pain 2 None 1
Value of GCS: Determine level of consciousness, severity of injury, prognosis
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentScore 3-15 13-15 MBI (Minimal Brain Injury) 9-12 Moderate Injury <8 Severe Injury ( coma)
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentSerious head injury:1- GCS ≤8.2- pupillary inequality.3- lateralized extremity weakness4- markedly depressed fracture.5- open cranial wound & brain exposed.
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentSigns of neurological deteriorations: 1- depressed level of consciousness. 2- bradycardia. 3- raising BP. 4- slow or irregular respiration. 5- increase neurological deficit or development of new one.
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery department
Decerebrated rigidity :occurs due to separation of brain stem from brain it self, bec. Excitation coming from brain stem will not be inhibited by the brain. Decorticated rigidity: occurs by isolation of cortex from other parts of the brain.
Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery departmentIndications of admission to hospital
Mosul university- College of dentistry-oral & maxillofacial surgery department1- unconscious patient. 2- progressive neurologic deficit. 3- progressive loss of consciousness. 4- history of trauma is unknown. 5- depressed fracture. 6- penetrating injury. 7- intracranial haematoma. 8- evidence of increase ICP.
Examination in head injury
Mosul university- College of dentistry-oral & maxillofacial surgery department■ Glasgow Coma Score■ Pupil size and response■ Lateralising signs■ Signs of base of skull fractureBilateral periorbital oedaema (raccoon eyes)Battle’s sign (bruising over mastoid)Cerebrospinal fluid rhinorrhoea or otorrhoeaHaemotympanum or bleeding from ear■ Full neurological examination: tone, power, sensation,reflexes
Pupillary Reflex
Pupils dilated with no constriction to bright lightMosul university- College of dentistry-oral & maxillofacial surgery department
Occulo-Vestibular Response“Cold Caloric Testing” Mosul university- College of dentistry-oral & maxillofacial surgery department
Eye Movements
Signs and symptoms
Mosul university- College of dentistry-oral & maxillofacial surgery departmentRaccoon eyes
Mosul university- College of dentistry-oral & maxillofacial surgery department
Battles signSigns and symptoms
Investigations
Mosul university- College of dentistry-oral & maxillofacial surgery department1- C.T 2- skull x-rays
CSF test
Mosul university- College of dentistry-oral & maxillofacial surgery departmentHalo sign
Management
Mosul university- College of dentistry-oral & maxillofacial surgery departmentBrain edema: excessive accumulation of water extra& intra-cellular spaces either vasogenic or cytotoxic.Medical –diuretics - hyperventilation - steroids - CSF aspiration - dopamine
Management
Mosul university- College of dentistry-oral & maxillofacial surgery departmentSkull fractures: Depressed fractures: indication for elevation: 1- if the fracture greater than the full thickness of skull. 2- if it is associated with extradural hematoma, brain laceration. 3- if it over important part of the cortex. 4- if it is associated with foreign body. 5- if there is neurological deficit.
Associated with skull fractures Tear in meningeal arteries S/S: LOC, lucid period, Management Medical Emergency Craniotomy or craniectomy
Mosul university- College of dentistry-oral & maxillofacial surgery department
Extradural Hematoma
Mosul university- College of dentistry-oral & maxillofacial surgery department
Extradural HematomaEtiology Acceleration/deceleration force Acute (-3rd day, chronic 3Wks) S/S: non, hemiparesis, Management Referral , surgery
Mosul university- College of dentistry-oral & maxillofacial surgery department
Subdural Hematoma
Skull Fracture
MechanismBlunt traumaTypes of fracturesS/SManagementABC’sCSF leakage Mosul university- College of dentistry-oral & maxillofacial surgery departmentComa patient care
Mosul university- College of dentistry-oral & maxillofacial surgery department1- airway a- oral or nasal tube b- endotracheal tube c- trachiostomy 2- fluid & electrolytes a- I.V. b- N.G. 3- bladder , bowel, bed sore 4- temperature regulation 5- treatment
Complications of Head injuries
Mosul university- College of dentistry-oral & maxillofacial surgery department1- post concussional syndrome 2- post traumatic amnesia 3- post traumatic epilepsy 4- brain death 5- CSF leaks (rhinorrhoea, otorrhoea)