Modified Essay Questions, MEQs in General Surgery - Head Injury

Head Injury

# A 32-year-old man was brought to the emergency by the police with history of a bike accident 3  hours ago. On examination he was confused and a lacerated wound was present on the scalp. His pulse was 120 bpm and BP 80 / 40 mm Hg. 
1. Perform a primary survey on the patient. 
- Write about ABCDE (Don't miss C spine collar in Airway and  Opening 2 wide bore IV cannula).

2. What further steps will you take in the management of this patient? 
Write about the secondary survey, control of hemorrhage, Investigations (laboratory, radiological).

3. Classify head injury: 
A. On the basis of GCS: 
- Minor head injury: GCS 15 with no loss of consciousness (LOC) 
- Mild head injury: GCS: 14 or 15 with LOC 
- Moderate head injury: GCS 9-13 
- Severe head injury: GCS 3-8 

B. On the basis of the time of injury: 
- Primary Brain Injury: Occurs at the time of impact and includes injuries such as contusions, lacerations, and diffuse axonal injury 
- Secondary Brain Injury: occurs some time after the moment of impact and is often preventable: hypoxia, hypontension, raised ICP, reduced cerebral perfusion pressure pyrexia 

C. Blunt or penetrating injury 

D: Morphological 
- Skull fractures: linear, depressed, comminuted, open or closed 
- Intracranial hematomas: extradural, subdural, subarachnoid or intracerebral 
- Brain injuries: contusion, lacerations, diffuse axonal injuries 

4. Write indications of CT in this patient.
--- According to NICE criteria,
  • Glasgow coma score < 13 at any point 
  • GCS 13 or 14 at 2 hours 
  • Focal neurological deficit 
  • Suspected open, depressed or basal skull fracture 
  • Seizure 
  • Vomiting > 1 episode 
Urgent CT Scan to be done if none of the above but:
  • Age > 65 
  • Coagulopathy 
  • Dangerous mechanism of injury (CT within 8 hours) 
  • Antegrade amnesia > 30 min (CT within 8 hours) 
5. Write 4 indications for admission of this patient. 
- Same as above 
- Depressed fractures, vomiting, loss of consciousness, focal neurological deficit etc.

6. What is damage control surgery? 
- Damage control surgery: It is based on the realization that minimizing surgery until the physiological derangements can be corrected is the best way of improving outcome in trauma patients.

In physiologically unstable patients: ie those with the deadly triad: hypothermia, acidosis, and coagulopathy, protracted surgery to treat all the injuries may actually increase the mortality rate. 

In damage control surgery the goal is restricted to: 
a. stopping any active bleeding 
b. controlling any contamination 

Steps of Damage control surgery 
a. patient selection 
b. control of hemorrhage and control of contamination 
c. resuscitation continued in the intensive care unit
d. definitive surgery 
e. abdominal closure 

7. How do you manage the head injury in this patient? 
# Emergency management 
- Management to prevent secondary brain injury: infection, hypoxia, raised ICP, pyrexia, hypoperfusion 

- Definitive management: according to investigations: draining of any hematoma either by burr hole or craniotomy.