MANAGEMENT OF HEAD INJURIES

Head injury, or more correctly brain injury, remains one of the most common and devastating injuries.  Head injury can be classified into primary and secondary injuries, depending on the degree of trauma suffered by the brain.

Different categories of Brain Injury 

Primary Injury

A primary injury is one in which the initial trauma damages the brain. This can range from mild concussion, to moderate brain contusion, to a severe life-threatening brain injury.

Secondary brain injuries are those that occur after the primary injury. Secondary injuries can be treated, and appropriate timely management can dramatically affect the outcome.  

Concussion occurs when there is an accelerated force to the brain. If the duration of unconsciousness is less than ten minutes and the patient is orientated and neurologically intact when they reach the emergency department, this is classified as mild concussion.  

A severe concussion will leave the patient with headaches, giddiness, grogginess, nausea and problems with short-term memory and concentration.

Bruising of the brain from injury leads to contusions, and the final neurologic sequelae depend on the site(s) of injury and severity. Grand mal or focal seizures are common and the patient often requires lifelong anti-convulsion treatment. Brain contusion can occur either from closed head injury, due to differential movement between the brain and the inner skull, or from an open penetrating injury. 

Another form of moderate brain injury is ‘shear’ injury where brain white fibres are torn. In such injuries, intracranial pressure (ICP) is not raised even though the patient may have varying degrees of neurologic deficit, including coma if the shear injury is severe. 

If the injury to the head is severe and the patient is immediately rendered unconscious and remains so, it is considered a major brain injury.

Active management of the unconscious patient must start at the site. After a quick examination, patient resuscitation and restoration of blood pressure and oxgenation are important. Resuscitation takes precedence over ICP-lowering medications. Approximately 66% of all head injuries are associated with spinal injury. The head and neck must be splintered and care must be taken with the entire spine during resuscitation and transport to the emergency department.

On arrival at the emergency department a CT scan on the brain and X-rays of the whole spine and chest should be performed as soon as the patient is stable. If there is an open injury to the brain, or if the CT scan shows evidence of a significant intracranial blood clot, an emergency operation is required.

As the patient makes progress, the level of care can be reduced. Rehabilitation is initially performed on an inpatient and eventually onto an outpatient basis. 80% of possible recovery occurs by three months. At this point it is possible to estimate the degree of disability, if any, of the patient. A further 20% of possible recovery will occur upto 24-30 months after the event. Beyond that, no more recovery and improvement can be expected.