Head injuries,symptoms, causes, pathology, types, examination, treatment, physio

 It is the insult to the brain caused by external physical force leading to altered conscious levels, cognitive problems as well as motor & sensory deficits. 

Commonly called traumatic brain injuries. 

Head injuries have increased due to increased traffic and decreased traffic sense. Most of the cases are proved to be fatal death. 

Incidence:- 

• High Head injuries from road traffic accidents are most common in young males. 
• RTA's although constituting only about 25% of all patients with head injury, are the cause of more severe injuries. 
• RTA's contribute to 60%of deaths from head injury, of these half die before reaching hospital. 

Causes of head injuries:-

• Road traffic accidents (RTA's) 
• Gunshot
• Riots 
• Blow or hit on the head
• Fall from heights. 

Pathology:-

• Primary brain damage - Occuring at impact
• Secondary brain damage - Occuring due to ongoing neuronal damage, haematoma, brain swelling, Ischaemia Or infection. 

Types of head injuries:-

 Focal & diffuse

Open & closed injuries

Open injuries are susceptible to infection. These are dangerous & life threatening unless treated immediately. 

Closed injuries - there is no injury to the skull only neural tissue is damaged.

Focal damage:-

• Contusion:- Brushing of the brain tissue is called contusion it is of 2types 1) coup lesions - Damage occurs directly under the impact & 2) centre coup lesions - Damage occurs under & opposite the site of impact. Contusion s are usually multiple & may occur bilaterally, immediate loss of consciousness. 
• Concussion:- It is a low grade (slow velocity) head injury It is characterized by immediate loss of consciousness but is regained after few minutes. Headache, nausea, vomiting, dizziness, Amnetia maybe present. 
• Intracranial Heamatoma:- Intracranial bleeding may occur either outside (extradural) or within the dura (intradural) Intradural lesions - Subdural+intracerebral, contusion in frontal & temporal lobe bleed into brain or onto brain surface on subdural haematoma, Intracerebral haematoma + Necrotic brain tissue rupturing out into subdural space is Burst lobe,, Extradural -- A skull fracture tearing the middle meningeal blood vessels bleeds into extradural space. This usually occur in temporal or parieto temporal region, extradural haematoma results from damage to the sagittal Or transverse sinus. 
• Tonsillar herniation:- An increase in the Intracranial pressure to a supratentorial haematoma initially produce a midline shift, lateral tentorial herniation, central tentorial herniation, brainstem damage. 

Diffuse damage :- 

Diffuse axonal injury:+ Caused by high velocity injuries. Shearing forces cause immediate mechanical damage to axons Depending on the severity of the injury, the effects may range from mild coma to death. 

Associated problems:-

• Increased intra cranial pressure
• Anoxia leads to loss of consciousness
• Head injury associated epilepsy
• Locked in syndrome

Investigation:- 

• Routine blood examination
• CT & MRI 
• X - ray 

Clinical features:-

• Altered level of consciousness
• Coma - state of un Consciousness 
• Stupor - State of  confusion
• Delirium - perceptual abnormality
• Obtundity - Disinterest in doing anything after prolong sleep. 
• Alternations in the ANS leads to change in BP, respiratory rate, sweating, salivation, lacrimation. 
• Loss of coordination, balance & equilibrium, sensation
• Aphasia, Dysphagia. 
• Loss of higher mental function like memory, intelligence, consciousness, behaviour orientation & speech. 
• Cranial nerves dysfunction. 

Management:-

1° Assessment :(coma patient) 

Check for airway - Check for any obstruction

Check for breathing - administer oxygen & check respiratory movement are adequate or not, if not then ventilate. 

Circulation - Check pulse & BP If patient is hypotensive, replace blood loss with IV fluids, followed by blood if HB is <10g/l

Head/ spinal injury - Assess concious levels & focal signs, check for any spinal injuries (X- ray spine) 

Limb injuries - Examine limb for laceration & fracture

Physiotherapy management:-

Acute and Subacute stage:-

Acute Stage :- Immediately after injury. 

• Positioning of the patient - determines the prognosis, side lying supporting with pillows, if the patient has an problem in side lying, (chest wall expansion), then make him supine in case of severe respiratory distress, prone lying - Pillows under thorax & shoulders & below abdomen & pelvis. 
• Use of water & air beds - to relieve pressure areas, to prevent increasing tone due to stretch reflex
• In case of any heterotrophic ossification- c/f - pain oedema, redness, swelling, decrease ROM) 
• Improve awareness of the patient by talking to him even he is not responding
• Sensory stimulation - Auditory stimulus - Playing favourite music, Relatives can talk to him to make him recollect things, Olfactory Stimulus - Favourite food smell or perfume, if patient is able to open his eyes - show him photographs of dear ones, dark coloured pictures, to initiate opening of mouth - cryotherapy  (icing on lips) Gustatory stimulus If patient is not responding to all above stimuli, give noxious stimulus at nail beds, supra orbital region. 
• ROM exercises:- Prophylaxis - DVT prophylaxis - Vigorous ankle pumps Pressure stocking, Chest PT - given after 2hrs of feeding, Chest percussion, suction tubes are used to remove secretion s. 

Subacute Management:-

• If patient is not managed properly in acute stage, Contractures deformities may develop
• Position the patient in such a way that there is some stretch to the muscles 
• Mobility exercises/flexibility exercises to the limbs
• Sensory reeducation
• Mobility training - make patient sit with support, weight shifting, trunk rotation, standing. 
• Improve tone and ROM
• If contractures are severe - serial easting
• Stretching & strengthening exercises
• Gait training - ADL activity training.