Head injuries
Head injuries is a wide chapter. These range from simple concussion to epidural or subdural hematomas to diffuse axonal damage. A large part of the photos is devoted to the management of the ICP (IntraCranial Pressure).

However, the essential message regarding head injuries remains preventive! It is much easier to avoid them than to treat them! Please wear a helmet when cycling, skiing, scootering, etc ... Please respect the speed limits! Thank you for wearing your seat belt! Please do not drive under the influence of alcohol or drugs!
Epidemiology of head injuries
Clinic - Classification of head injuries
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Classification :

 

There are many classifications of head injuries. The simplest is based on the Glasgow score.

The advantage of such classifications is essentially to be able to compare the results or strategies between the centers and to facilitate the establishment of management recommendations (guidelines)

Glasgow Score :

 

The Glasgow score is based on 3 parameters:

  • Eye opening

  • Motor response

  • Verbal response

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Eye opening (1-4) :

 

Eye opening is rated on a scale of 1 (worst) to 4 (best):

  1. No eye opening

  2. Eye opening to pain

  3. Eye opening on command

  4. Spontaneous eye opening

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Motor response (1-6) :

 

Motor response is rated on a scale of 1 (worst) to 6 (best):

  1. No motor response

  2. Motor response in extension (decerebration posture)

  3. Motor response in abnormal flexion (decortication posture)

  4. Motor receding response to pain

  5. Pain location

  6. Response to orders

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Verbal response (1-5) :

 

The verbal response is rated on a scale of 1 (worst) to 5 (best):

  1. No verbal response

  2. Emission of incomprehensible sounds

  3. Inappropriate words

  4. Disorientation

  5. Orientation

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Glasgow Score :

 

The total score therefore varies between 3 and 15.

When there is a difference in response between the right and the left, it is the best response that matters.

When the examination is performed several times in a short period of time, it is also the best answer that matters.

The Glasgow score has been shown to be highly reproducible within a single occupational group (e.g. several nurses will achieve the same score), but tends to increase with specialization (a clinical manager will readily obtain a score higher than an assistant physician).
The Glasgow score is dynamic and varies over time. Due to the variability between occupational groups, it is preferable that this score be systematically performed by the same occupational category.
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Assessment of head injuries :

 

The purpose of the Glasgow score is to assess the patient's state of consciousness, but other clinical elements are also important:

  • Brainstem reflexes

  • Restricted neurological examination

  • Cardiorespiratory assessment

The clinic alone does not allow optimal management of TBI and the cerebral (CT-scan, ...) and spinal (cervical x-ray, CT-scan, ...) radiological assessment is also part of the basic assessment.

Management of head injuries
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Management of head injuries :

 

The major problem in the management of head injuries is that it influences the future of only a minority of patients and this can lead to a demotivation of the care teams taken with an extreme fatalism. However, once this data is integrated, the strategies developed to optimize the management of traumatic brain injuries take on their full meaning.

Before going into the details of the care of head injuries, it is necessary to know the different pathologies that one can meet.

Focal lesions vs diffuse lesions
There are 2 main categories of lesions in head injuries: a) focal lesions and b) diffuse lesions. Very often these 2 types of lesions are associated, but with a very variable weighting. In order to better understand their respective treatments, they are described separately.
Focal lesions
Focal lesions :

 

Focal lesions can involve the envelopes of the brain or the brain itself.

The main focal lesions are:

  • Epidural hematoma

  • Acute subdural hematoma

  • Chronic subdural hematoma

  • Brain contusions

  • Intracerebral hematoma

  • Embedded fracture

  • Carotid-cavernous fistula

  • Base fracture

  • Direct cerebral wounds (bullet, perforating object, ...)

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Epidural hematoma
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Acute subdural hematoma
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Chronic subdural hematoma
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Brain contusions
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Depressed skull fracture
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Skull base fracture
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Perforating wounds
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Carotid-cavernous fistula
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Diffuse lesions
Concussion
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Diffuse axonal lesions
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Management of severe head injuries
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While keeping in mind that the efforts in the management will only impact on a minority of patients, there are essentially 3 goals in the acute treatment of head injuries:
  • Minimize the impact of primary lesions (eg: evacuation of an epidural hematoma)
  • Avoid or minimize secondary lesions (eg: related to intracranial hypertension)
  • Avoid extra-cerebral complications (eg ulcer)
Once the acute phase has passed, the aim of management will be to maximize functional recovery.
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Intracranial hypertension
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Brain death
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