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Emergency Procedure and Patient
Care-Lec-6
BY
Asghar
Director/Associate professor
Riphah College of Rehabilitation Sciences(RCRS)
Riphah International University Islamabad
Head Injuries
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Pathomechanics of brain injuries
Types of pathology
Classification of cerebral concussion
Cerebral contusion
Cerebral hematoma
Second impact syndrome
Initial on site assessment
Sideline assessment
Special tests for assessment of coordination
Special tests for assessment of cognition
Other tests
Medications
Wake ups and rest
Pathomechanics of Brain Injuries
• Cerebral concussion can be defined as any transient
neurological dysfunction resulting from an applied force to
the head.
• A forceful blow to the resting movable head usually produces
maximum brain injury beneath the point of cranial
impact.This is known as a coup injury.
• A moving head hitting against an unyielding object usually
produces maximum brain injury opposite the site of cranial
impact (countercoup injury) as the brain rebounds
within the cranium.
Pathomechanics of Brain Injuries
• Three types of stresses can be generated by an applied force
when considering injury to the brain:
• Compressive: Compression involves a crushing force
whereby the tissue cannot absorb any additional force or
load.
• Tensile : Tension involves pulling or stretching of tissue
• Shearing: Shearing involves a force that moves across the parallel
organization of the tissue
Types of Pathology
 Traumatic brain injury (TBI), which can be
classified into two types: focal and diffuse.
 Focal brain injuries are posttraumatic intracranial mass
lesions that may include subdural hematomas, epidural
hematomas, cerebral contusions, and intracerebral
hemorrhages and hematomas.
Focal Brain Injuries
 Signs and symptoms of these focal vascular emergencies can
include:
 Loss of consciousness
 Cranial-nerve deficits
 Mental-status deterioration
 Worsening symptoms
Diffuse Brain Injuries
• Diffuse brain injuries can result in widespread or global disruption
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of neurological function and are not usually associated with
macroscopically visible brain lesions except in the most severe
cases.
Most diffuse injuries involve an acceleration–deceleration motion,
either within a linear plane or in a rotational direction, or both.
In these cases, lesions are caused by the brain essentially being
shaken within the skull.
The brain is suspended within the skull in CSF and has several
dural attachments to bony ridges that make up the inner contours
of the skull.
With a linear acceleration–deceleration mechanism (side to side
or front to back), the brain experiences a sudden momentum
change that can result in tissue damage.
Classification of Cerebral Concussion
• Concussion is caused by a direct blow to the head or
elsewhere on the body, resulting in a sudden mechanical
loading of the head that generates turbulent rotatory and
other movements of the cerebral hemispheres.
• Concussion is most often associated with normal
results on conventional neuroimaging studies, such as
magnetic resonance imaging (MRI) or computed tomography
(CT) scan
Mild Concussion
• The mild concussion, which is the most frequently occurring
(approximately 85%), is the most difficult head injury to
recognize and diagnose.
• The force of impact causes a transient aberration in the
electrophysiology of the brain substance, creating an alteration in
mental status.
• Mild concussion involves no loss of consciousness, dizziness and
tinnitus (ringing in the ears) may also occur, but there is rarely a
gross loss of coordination that can be detected with a Romberg
test. The clinician should never underestimate the presence of a
headache, which presents to some degree in nearly all
concussions.
• The intensity and duration of the headache can be an indication of
whether the injury is improving or worsening over time.
Moderate Concussion
• The moderate concussion is often associated with transient
mental confusion, tinnitus, moderate dizziness, unsteadiness
and prolonged posttraumatic amnesia
(30 minutes).
• A momentary loss of consciousness often results, lasting from
several seconds up to 1 minute.
• Blurred vision, dizziness, balance disturbances, and nausea
may also be present.
Severe Concussion
• It is not difficult to recognize a severe concussion because
these injuries present with signs and symptoms lasting
significantly longer than those of mild and moderate
concussions.
• Most experts agree that a concussion resulting in prolonged
loss of consciousness should be classified as a severe
concussion.
• Neuromuscular coordination is markedly compromised, with
severe mental confusion, tinnitus, and dizziness.
Cerebral Contusion
• The brain substance may suffer a cerebral contusion
(bruising)
• when an object hits the skull or visa versa. The impact causes
injured vessels to bleed internally, and there is a associated
loss of consciousness.
• A cerebral contusion may be associated with partial paralysis
or hemiplegia, one-sided pupil dilation, or altered vital signs
and may last for a prolonged period.
• Progressive swelling (edema) may further compromise brain
tissue not injured in the original trauma.
Cerebral Hematoma
• The skull fits the brain like a custom-made helmet, leaving
little room for space-occupying lesions like blood clots.
• Blood clots, or cerebral hematomas, are of two types,
epidural and subdural, depending on whether they are
outside or inside the dura mater.
• Each of these can cause an increase in intracranial pressure
and shifting of the cerebral hemispheres away from the
hematoma.
• The development of the hematoma may lead to deteriorating
neurological signs and symptoms typically related to the
intracranial pressure.
Epidural Hematoma
• An epidural hematoma most commonly results from a severe
blow to the head that typically produces a skull
fracture in the temporoparietal region.
• These are usually isolated injuries involving acceleration–
deceleration of the head, with the skull sustaining the major
impact forces and absorbing the resultant kinetic energy.
• The epidural hematoma involves an accumulation of blood
between the dura mater and the inner surface of the skull as a
result of an arterial bleed—most often from the middle meningeal
artery.
• These are typically fast-developing hematomas leading to a
deteriorating neurological status within 10 minutes to 2 hrs
Subdural Hematoma
• The mechanism of the subdural hematoma is more complex.
• The force of a blow to the skull thrusts the brain against the point of
impact. As a result, the subdural vessels stretch and tear, leading to the
development of a hematoma in the subdural space.
• Bleeding into the subdural space is typically venous in origin; the
resultant hematoma will therefore accumulate over a longer period of
time compared to an epidural hematoma.
• This pathology has been divided into acute subdural hematoma, which
presents in 48 to 72 hours after injury, and chronic subdural hematoma,
which occurs in a later time frame with more variable clinical
manifestations.
• As bleeding produces low pressure with slow clot formation, symptoms
may not become evident until hours or days (acute) or even weeks later
(chronic), when the clot may absorb fluid and expand.
Intracerebral Contusion and
Hemorrhage
• A cerebral contusion is a heterogeneous zone of brain
damage that consists of hemorrhage, cerebral infarction,
necrosis, and edema.
• Cerebral contusion is a frequent sequela of head injury and is
often considered the most common traumatic lesion of the
brain visualized using imaging studies.
• Typically, these are a result of an inward deformation of the
skull at the impact site
Second Impact Syndrome(SIS)
• SIS occurs when a person who has sustained an initial head
trauma, most often a concussion, sustains a second injury
before symptoms associated with the first have totally
resolved. Often, the first injury was unreported or
unrecognized.
• SIS usually occurs within 1 week of the initial injury and
involves rapid brain swelling and herniation as a result of the
brain losing autoregulation of its blood supply.
• Brain stem failure develops in 2 to 5 minutes, causing rapidly
dilating pupils, loss of eye movement, respiratory failure, and
eventually coma.
On-Site Assessment
 Primary Survey:
 Rule out life-threatening condition History Mental confusion
 Check respirations (breathing)
 Check cardiac status
 Secondary Survey
 History: Mental confusion, Loss of consciousness, Amnesia
 Observation: Monitor eyes,Deformities, abnormal facial
expressions, speech patterns, respirations, extremity movement
 Palpation :Skull and cervical spine abnormalities
Pulse and blood pressure (if deteriorating)
Cranial Nerves: Function and
Assessment
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Nerve Name
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I -Olfactory
Sense of smell
Identify odor
II -Optic
Vision
Check for blurred or double vision
III- Oculomotor Control size of pupil, some eye motions Check pupil reactivity; check upward and
downward eye motion
IV -Trochlear
Some eye motions
Check lateral eye motion
V-Trigeminal
Jaw muscles
Check ability to keep mouth closed
VI- Abducens
Some eye motions
Check lateral and medial eye motion
VII- Facial
Some facial muscles
Check ability to squeeze eyes closed tightly
or “big smile”
VIII-Vestibulocochlear Hearing; balance
Check for loss of hearing on one side;
balance testing
IX- Glossopharyngeal Gag reflex
Check ability to swallow
X-Vagus
Controls voice muscles
Check ability to say “ahhh”
XI- Accessory Innervate trapezius muscles
Check resisted shoulder shrug
XII- Hypoglossal Motor function of tongue
Check ability to stick out tongue
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Function
Assessment
Six testing conditions for the Balance Error Scoring System (BESS).
Double-leg stance on firm
surface
Single-leg stance on firm
surface
Tandem on firm surface.
Double-leg stance on foam
surface
Single-leg stance on foam
surface
Tandem on foam surface
Physical Therapy Management
• Pain management
• Positioning
• Balance
• Coordination
• Muscle strength
• ROM
• Endurance
• Gait training