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Head Trauma

Traumatic head injuries are a major cause of death, and disability but it might be best to refer to the damage done as traumatic brain injury.

The purpose of the head, including the skull and face, is to protect the brain against injury. In addition to the bony protection, the brain is covered in tough fibrous layers called meninges and bathed in fluid that may provide a little shock absorption.

When an injury occurs, loss of brain function can occur even without visible damage to the head. Force applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the brain tissue, or damage the nerve connections within the brain.

Caring for the victim with a head injury begins with making certain that the ABCs of resuscitation are addressed (airway, breathing, circulation). Many individuals with head injuries are multiple trauma victims and the care of their brain may take place at the same time other injuries are stabilized and treated.

Causes

Adults suffer head injuries most frequently due to falls, motor vehicle crashes, colliding or being struck by an object, and assaults. Falls and being struck are the most common causes of head injury in children.

Symptoms

It is important to remember that a head injury can have different symptoms and signs, ranging from a patient experiencing no initial symptoms to coma.

A high index of suspicion that a head injury may exist is important, depending upon the mechanism of injury and the initial symptoms displayed by the patient. Being unconscious, even for a short period of time is not normal. Prolonged confusion, seizures, and multiple episodes of vomiting should be signs that prompt medical attention is needed.

In some situations, concussion-type symptoms can be missed. Patients may experience difficulty concentrating, increased mood swings, lethargy or aggression, and altered sleep habits among other symptoms. Medical evaluation is always wise even well after the injury has occured.

Diagnosis

The physical examination and the history of the exact details of the injury are the first steps in caring for a patient with head injury. The patient's past medical history and medication usage will also be important factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is more important to assess brain function than to look at the bones that surround the brain. Plain X-ray films may be considered in infants to look for a fracture, depending upon the clinical situation.

Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and patients suffering axonal shear injury may be comatose with a normal CT scan of the head.

Treatment

Once the severity and nature of your head injury has been diagnosed, you will be given appropriate treatment. A severe head injury must always be treated in hospital to minimise the risk of complications.

Initial treatment

When you arrive at the emergency department of a hospital, or if you call an ambulance, the doctors or paramedics (members of the emergency medical services) treating you will prioritise any injury that may be life threatening. This could mean:

  • checking your airway is clear
  • checking you are breathing, and starting cardio-pulmonary resuscitation (CPR or mouth-to-mouth) if you are not
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  • stabilising your neck and spine, for example using a neck brace
  • stopping any severe bleeding
  • providing pain relief if you are in a lot of pain
  • splinting any fractured or broken bones (strapping them into the correct position)

Once you are stable, further treatment will be arranged, as necessary, including any tests you need to help determine the severity of your injury. Read more about diagnosing a severe head injury for more information about tests you may have.

Observation

If you need to stay in hospital for observation, doctors and nurses treating you will check:

 
  • your Glasgow Coma Scale (GCS) score (a scale of 3 to 15 that assesses the extent of damage to your brain)
  • the size of your pupils (the black circles in the middle of each eye) and how well they react to light
  • how well you can move your arms and legs
  • your breathing
  • your heart rate
  • your blood pressure
  • your temperature
  • the level of oxygen in your blood

These checks will be made every half an hour until your GCS score is 15 (the highest possible score). A GCS score of 15 indicates that you know where and who you are, you can speak and move as instructed and your eyes are open. After this, checks will be made less frequently. Any changes in your condition or behaviour will also be closely monitored. If your condition worsens, you may need to have further tests, such as a computerised tomography (CT) scan (a scan that produces images of the inside of your body).

Cuts and grazes

If you have any external cuts or grazes to your head, these will be cleaned and treated to prevent further bleeding or infection. Deep or large cuts may require stitches (sutures) to keep them closed until they heal. Local anaesthetic (a painkilling medication) may be used to numb the area around the cut so you do not feel any pain.

Neurosurgery

Neurosurgery is any kind of surgery used to treat a problem with the nervous system (the brain, spinal cord and nerves). In cases of severe head injury, neurosurgery is usually carried out on the brain. Neurosurgery is required in 1-3% of people with a severe head injury. Every year in the UK, it is estimated that just under 4,000 people have neurosurgery following a head injury.

  • a haemorrhage (severe bleeding) inside your head, which puts pressure on the brain and may result in brain injury (brain damage) and, in severe cases, death
  • a haematoma (blood clot) inside your head, which can also put pressure on the brain
  • cerebral contusions (bruises on the brain), which can develop into blood clots
  • skull fracture (see below)

These conditions will be identified during tests, such as a CT scan, and a neurosurgeon (an expert in surgery of the brain and nervous system) may come and speak to you or your family about whether surgery is necessary. As the above conditions can be serious and may require urgent treatment, in some cases there may not be time to discuss the surgery before it is carried out. After the operation, your surgeon will take the time to discuss the details of the surgery with both you and your family. One possible type of surgery that may be required is a craniotomy.

Craniotomy

A craniotomy is a type of surgery that involves making a hole in your skull (the bone in your head that surrounds your brain) so that the surgeon can access your brain. This will be carried out under general anaesthetic so that you are unconscious and cannot feel anything. Once your surgeon has access to your brain, they will remove any blood clots that may have formed and repair any damaged blood vessels. Once any bleeding inside your brain has stopped, the piece of skull bone will be replaced and reattached.

Other surgical procedures

Depending on the type of damage to your brain, there are a number of other possible surgical procedures. Ask your surgeon for more information or see below if you have one of these conditions:

  • a subdural haematoma is a blood clot that forms in the space between the brain and the skull
  • a subarachnoid haemorrhage is where blood leaks out of blood vessels over the surface of the brain

Skull fractures

Your skull can fracture (crack) during an injury to your head. If this happens, you will usually have an X-ray to determine the extent of the injury. There are different types of skull fractures, including:

  • simple (or closed) fracture, where the skin has not broken and the surrounding tissue is not damaged
  • compound (or open) fracture, where the skin has broken and the surrounding tissue may be damaged
  • linear fracture, where the break in the bone looks like a straight line
  • depressed fracture, where part of the skull is crushed inwards

Open fractures may be more serious because there is a higher risk of infection if the skin is broken. This is because bacteria could enter the wound through the open skin. Depressed fractures may also be more serious because small pieces of bone can press inwards against the brain.

Treating skull fractures

Most skull fractures will heal by themselves, particularly if they are simple, linear fractures. The healing process can take many months, although any pain will usually disappear in around 5-10 days. If the fracture is open, you may be prescribed antibiotics (medicines to treat infections caused by bacteria) to prevent an infection.

If the fracture is severe or depressed, you may need surgery to help prevent any damage to the brain. This will usually be carried out under general anaesthetic.

During your operation, any pieces of bone that have been pressed inwards can be removed and returned to their correct position. If necessary, metal wire or mesh may be used to reconnect the pieces of your skull. Once the bone is back in place, it should heal naturally. If you wish, your surgeon will explain the procedure you are having in more detail.

Skull fractures

Your skull can fracture (crack) during an injury to your head. If this happens, you will usually have an X-ray to determine the extent of the injury. There are different types of skull fractures, including:

After surgery

Depending on how serious your operation was, you may need to recover in an intensive care unit (ICU). This is a small, specialised ward where your condition will be constantly monitored. In an intensive care unit, you may be placed on a ventilator. This is an artificial breathing machine that moves oxygen-enriched air in and out of your lungs. The ventilator takes over some of your body’s usual responsibilities, such as breathing, giving your body time to recover. Once you are well enough, you will be moved to a ward and your condition will be observed, as described above.

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I was a patient for Surgery. I had an opportunity to know the functioning of the hospital in detail. Management is Excellent. Staff treatment to patients is remarkable & worthy. Patients gain confidence from the treatment. I am sure by passage of time the institution will be unchallenged in the state.

  • Patient: Master Ajit Kumar   

This is a wonderful hospital. The doctors & support staff are very co-operative and amiable. The way in which medical treatment is rendered with a humane touch is extremely praiseworthy.

  • Patient: Mr.Rabiul Haque   

We want to express our appreciation for your wonderful hospital and even more wonderful staff. Everyone we met during my stay was considerate, professional while still being friendly and caring. We don't have a lot of experience with hospitals, but we know quality when we experience it. Your facility was spotlessly clean and designed to make your patients comfortable and the family and friends feel welcome and comfortable as well. We cannot thank you enough for providing such a comforting, but top-notch environment for what was for us, a very scary procedure. Everyone, and I mean everyone, we were in contact with were wonderful. Thank you for providing such a fine group of care-givers and facility.

  • Patient: Ms.Anushka   
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