Head injury


  1. Road accident
  2. Assault
  3. Falls
  4. Sporting injuries
  5. Birth trauma




Fractures along the lines of stress, not at point of impact. Complications:
  1. bleeding: epidural, subdural
  2. CN palsies: I or VII VIII or III IV VI or II
  3. CSF leakage: rhinorrhoea, otorrhoea, air on radiograph/CT


Contusion: Coup and contra-coup injury.
Laceration: lesser wing of sphenoid, falx cerebri, tentorium cerebelli
Rotational: diffuse axonal injury (decorticates pt.)
Coma: reticular activating system (tethered below by dentate ligaments but not tethered above)
Autonomic: Motor: decerebrate.

Natural Hx

↑ICP (haemorrhage, cerebral oedema), which is compensated for by:
  1. CSF displaced
  2. Veins compressed
  3. Cushing's reflex (↑systolic BP, bradycardia)
  1. Transtentorial herniation (CNIII palsy, brain stem functions ↓↓, consciousness↓)
  2. 2°infarction
  3. Venous congestion
  4. CSF accumulation



Time of injury. Pt's condition. ATLS algorithm. ITU 1/4 h obs. Rate of deterioration: ABG, CXR (CO2 retention).
Then CT head or angiogram under LA or burr holes (min 6).
Cerebral oedema:
  1. elective ventilation therapy,
  2. thiopentone,
  3. ↓T°
  4. surgical decompression
Recovery is hierarchical: brain stem functions recover first. Higher cortical functions recover last (or not at all).
Recovery is exponential: 90% in first year. 90% of that in first 6/12. Tails off at 2 y. Any deficit at 2 y is permanent.
Epilepsy 5% risk: prophylactic anti-convulsants 6/12 to 1 y. If the pt. develops epilepsy then probably anticonvulsants for life.