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The Event Physician Head Injuries

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The Event Physician Head Injuries The Event Physician Head Injuries Emergency Sports Medicine Scalp lacerations and bleeding • Scalp wounds may bleed profusely- must be stopped. • Suturing is usually adequate • Difficult on field of play • Venous -digital compression • Bleeding that does not stop ~arterial in origin ~ fracture? • digital compression should not be excessive ~ risk of pressing fractured bone further into the cranium. • cover wound- use turban bandage. Occasionally, i.v. fluid may be needed if blood loss is significant Cranial/Cerebral injuries • common in sports • Some serious, most are not • 6 issues we must be concerned about • Scalp wounds • Cranial Fractures • Cerebral Contusions • Cerebral Hematomas • Cerebral Oedema • Concussion • Concomitant neck injuries Anatomy: • Scalp • Cranium and face - 22 bones • Mandible – only movable • Cerebrum + meninges • Sinuses – absorb force Brain • Well protected by meninges and skull • Sinuses • CSF • Brain no energy stores ~constant supply of blood and O2 • Therefore – sensitive to reduced blood flow/O2 Fracture types • external cranium is exposed to compression forces at point of contact, whereas internal bone is exposed to tensile forces • If point of contact is thick and strong, then the energy may be conducted around the cranium and cause a fracture at a weaker point. • Intracranial lesions accompany roughly two-thirds of skull fractures • Open fractures ~infection, air entry, meningitis or pneumocephalus CSF leakage • Linear fractures – commonest • Splinter fractures – after blow • Compression / impression fractues – extremely dangerous • Penetrating fractures Localisation: • Frontal – often depressed and if so, associated with brain contusions • Parietal • Temporal – associated with epidural hematomas - linear, can spread to basis • Occipital • Basilar ~CSF leakage from the ear or nose, blood behind the tympanum (hemotympanum), Battle’s Sign and Raccoon Eyes. Inspection: • Local Inspection for cuts and bruises • ? depressed fracture l – so look for but don’t press on indentations • Large hematoma over a fracture • Pain and tenderness • Penetrating wounds skade f.eks. spiker etc • CSF leakage ears, mouth, nose. Sweet taste sugar CSF. Inspection: • bleeding nose may indicate basal fracture, a bleeding ear almost always does. • examine ear canals and drums- no bleeding, but blood behind an intact drum, may indicate a basal fracture. • Thickening of the temporalis muscle – facial, cranial fracture? • Blood may also come from the mouth • Battle's sign • Binocular Hematomas – note the white corneas – no bleeding - Basilar fractures Battle’s Sign Battle’s Sign – mastoid ecchymosis, indicates posterior basilar fracture, but absence does not exclude a fracture. Binocular Hematoma Note clear white cornea Subconjunctival Hematoma • Can be present with a basilar fracture Clinical findings – cranial fracture • As with TBI • Neurological findings and altered states of consciousness • Hypotension (severe head injury – impending shock or death/ bleeding other source) • Hypertension (in mild or moderate TBI, body compensate blood loss via by vasoconstriction, resulting in elevated blood pressure). May also occur in acute spinal injuries. Clinical findings 2 – cranial fracture • Increased respiratory Rate – the body tries to compensate for trauma induced cerebral hypoxia by breathing faster. • Decreased Respiratory rate – may be sign of a major TBI and impending death. • Raised Temperature – mild increase found with TBI; beware Meningitis, encephalitis or other systemic infections as cause of collapse - not TBI/combo. Treatment cranial fractures: • treat any life-threatening complications first • stabilise cranial (and cervical) fractures • constant re-appraisal of Vital signs, Level of consciousness, Neurological deterioration • ABC/ Oksygen • Stop bleeding NB Cranium • Cover wounds • Do not remove foreign bodies or bone fragments Always • Maintain patent airways • max Oxygen supply, 12 – 15 L, 100% • Apply semi-rigid cervical collar • Maintain Ventilation • Stop scalp, non-intracranial hemorrhage • Establish i.v. lines and give adequate fluid – not too much – normo-tension is the goal. • Cover cranial and other wounds • Spine board or vacuum mattress • Elevate the head • Don’t lie on wound • Cont. Neuro evaluation • Use checklist Never • Never Remove penetrating intracranial foreign bodies – bleeding will worsen • Never Compress arterial bleeding from a cranial fracture site; digital pressure will probably not stop the bleeding and may worsen the bleeding by pressing bone fragments further into the brain Transport and contact • patient supine position with the Head elevated • patient should not lie on wound or fracture site • Continuous neurological evaluation – use check list • Continuous respiratory and circulatory evaluation • Ensure correct cervical and spinal immobilisation • Ensure careful lifting and movement of the patient. • Contact with hospital: • Inform the hospital of the patients status and expected time of arrival, deterioration - recontact Ding dong Traumatic Brain Injury TBI • Concussion • Contusion - oedema • Cerebral Hematoma Shearing, Bleeding and hematoma Shearing or torsional forces – white matter vessels damaged/ bleeding –tissue ischemia/ dural vessel damage - hematoma/ raised ICP/ reduced blood to brain tissue. Cerebral tissue ischemia and swelling/oedema leads to a lower PO2 and a higher PCO2. Raised PCO2 stimulates a vasodilation of arterial vessels, which results in further raised ICP. Pressure further compresses dilated arteries and further interferes with cerebral blood flow to already ischemic blood cells and thus worsens the ischemia. Injury site • Area of contact (coup) • Bouncing (contrecoup) • Occasionally sutures – dura is ripped off Anatomy of a man’s brain Predisposing conditions: • coagulopathy and anticoagulant therapy • depressed skull fracture or basilar fracture, • focal neurologic deficits, • multiple injuries, • shunt-treated hydrocephalus • AND LAST BUT NOT LEAST a recent history of head injury Concussion • after a blow • No CT signs of brain injury • Diagnosis • Loss of consciousness - LOC • Headache, nausea, vomiting • Amnesia (minutes-hours) - retrograde amnesia • Impaired intellectual function One of the issues that was speculated upon at the Vienna conference was whether concussion represents a unitary phenomenon with a linear spectrum of injury severity or whether Types of concussion • different concussion sub-types exist and may present with different clinical manifestations (confusion, memory problems, loss of consciousness) • may be dependent on anatomic localization (cerebral, brain stem) • biomechanical impact (rotational or linear force) • genetic phenotype (ApoE4 positive or negative) • neuropathological change (structural injury, no structural injury) or an as yet undefined difference. • factors may be independent or combined • Must be several types as clinical outcome with the same impact force cause different clinical findings LOC - significance • Traditional evaluation groundstone • Still relevant if prolonged • Used to be primary measure of severity • limitations in sporting concussive injury. • Studies imply that short term LOC is not associated severity • LOC not necessarily ~complex concussion • LOC is a very important finding if non-concussive head injury present – i.e. hematoma, contusion Amnesia – Significance! • Maybe more important • new interest • role of post-traumatic amnesia as a measure of injury severity? • Publications seem to imply that the sum of symptoms, severity and duration of the clinical post-concussive symptoms may be more important than the presence or duration of amnesia alone. • Further it must be noted that retrograde amnesia varies with the time of measurement post-injury and hence is poorly reflective of injury severity. Cerebral contusion: • brain exposed to external forces - bruising • direct, indirect contrecoup ichemia and necrosis • smaller arteries, petechial hemorrhage, swelling of the brain tissue due to edema and even tissue destruction • ischemic damage~arterial injury • findings vary with location and size of the brain contusion • frontal and temporal regions (often basal aspects of) most common Cerebral Contusion: • CT scan • R. extensive bruising - large, diffuse grey area • White patches within grey - bleeding. • grey represents oedema • cortical contusion – purple • Cm scale to measure level of oedema • "Cortical contusion > 1cm in diameter. Frontal Lobe • Frontal Lobes • most vulnerable, commonest injury site mild - moderate TBI • may result in • difficulty in speaking • formulating response • disturbance or loss of fine movements and strength of the arms, hands and fingers • reduced facial expressions. Temporal Lobe • Temporal Lobes • Disturbed hearing • difficulty in recognizing faces • difficulty in understanding spoken words • Short-term memory loss • right lobe damage can cause persistent talking, increased aggressive behaviour. Parietal Lobe • Parietal Lobes – Damage may cause several unusual symptoms • Inability to name an object (Anomia) • difficulty reading (Alexia) • difficulty with drawing object • difficulty in distinguishing left from right • Apraxia • difficulties with eye and hand coordination. Occipital Lobe • Occipital Lobes – • Visual Field defects, difficulty with identifying colors (Color Agnosia), Visual illusions - inaccurately seeing objects, Word blindness, difficulty in recognizing drawn objects. Difficulties with reading and writing. Dysautoregulation Syndrome • Diffuse cerebral
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