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INTRODUCTION

Head injury is an alteration in mental or physical functioning of the brain. Any injury to the head may cause traumatic brain injury (TBI). It can be defined also as any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.  The Loss of consciousness does not necessarily need to occur though in many cases it is there. There are two major types of TBI:

Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.

Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage:

Primary brain damage, which is damage that is complete at the time of impact, and may include a skull fracture, contusions or bruises, hematomas or blood clots, lacerations and nerve damage.

Secondary brain damage, which is damage that evolves over time after the trauma, may include:

• brain swelling (edema)
• increased pressure inside of the skull (intracranial pressure)
• epilepsy
• intracranial infection
• fever
• hematoma
• low or high blood pressure
• low sodium
• anemia
• too much or too little carbon dioxide
• abnormal blood coagulation
• cardiac changes
• lung changes
• nutritional changes

There are many more consequences that result from head injuries.

Physical problems may include hearing loss, ringing or buzzing in the ears, headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, and reduced strength and coordination in the body, arms, and legs.

Traumatic head injuries have costed so many nations a lot of money especially developed countries because of the increased number of vehicles, theft, conflicts etc.

The Glasgow Coma Scale (GCS) developed by Jennett and Teasdale is used to describe the general level of consciousness of patients with TBI and to define broad categories of head injury. It is often used to help define the severity of TBI. Mild head injuries are generally defined as those associated with a GCS score of 13-15, and moderate head injuries are those associated with a GCS score of 9-12. A GCS score of 8 or less defines a severe head injury.

ANATOMY OF THE HEAD

 Skull: it’s the skeleton of the head that forms the cranium and facial skeleton. The cranium encloses the brain and its coverings, some parts of the cranial nerves and blood vesses. There are about 22 bones that are joined to form the skull. These are: 2 parietal,2 temporal, 1 frontal, 1 occipital, 1 ethmoid, 1 sphenoid, 2 maxilla, 2 zygomatic, 1 mandible,2 nasal, 2 palatine, 2 inferior nasal concha, 2 lacrimal and 1 vomer.

Cranial nerves: these are nerves that transmit impuses from sense organs. They are twelve in number and their naming correspond to their area of function. In order of increasing numbers these are: Olfactory, Optic, Oculomotor, Trochlea, Trigeminal, Abducens, Facial, Vestibulocochlea, Glossopharyngeal, vagus, Accesory and Hypoglossal cranial nerves.

 CAUSES/ETIOLOGY OF HEAD INJURY

While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma.

Motor vehicle accidents account for almost half of the TBIs in suburban/rural settings. In cities with populations greater than 100,000, assaults, falls, and penetrating trauma are more common etiologies of head injury. The male-to-female ratio for TBI is nearly 2:1, and TBI is much more common in persons younger than 35 years.

INCIDENCE/PREVALENCE

All cases of traumatic brain injury are supposed to be treated as an emergency. Different countries have different prevalence rates depending on the economical stability of the country.                                                                                                                                                                                                                                            As many as 10% of these injuries are fatal, resulting in a lot of persons hospitalization.

 Head injury data are difficult to compare internationally for multiple reasons, including inconsistencies and complexities of diagnostic coding and inclusion criteria, case definitions, ascertainment criteria (for example, hospital admissions versus door-to-door surveys), transfers to multiple care facilities (for example, patient admissions may be counted more than once), and adding to this complexity is the finding that some individuals with cognitive and emotional sequelae from mild head injury may not establish the casual connection between their injury and its consequences. Such patients may not seek treatment and may not be expressed in official demographic data.

DIAGNOSIS

As with most injuries and illnesses, finding out what happened to the patient is very important. The information may be provided by the patient, people who witnessed the event, emergency medical personnel, and if applicable, the police. The circumstances are very important since it is important to find out the severity and intensity of the trauma sustained by the head.

Physical examination begins with assessing the ABCs (airway, breathing, circulation) to make certain that the patient is stable and does not need emergent life-saving interventions. This is especially important in those patients who are unconscious and may not be able to maintain their own airway or breathe on their own.

If the patient is not fully awake, the examination will initially try to determine the level of coma using the Glosgol Coma Scale.

If no other injuries are found on examining the body, attention will be paid to the head and the neurologic exam. The neurologic exam may include evaluation of the cranial nerves, the short nerves that leave the brain and control the face muscles, eye movements, swallowing, hearing and sight, among other functions. Apart from the case history and the physical examination, diagnosis of TBI will also involve the following:

·         CT scan

·         MRI

·         Radiography

 SIGNS AND SYMPTOMS

The symptoms of a head injury can occur immediately or develop slowly over several hours or days. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull. The following symptoms suggest a more serious head injury signs and symptoms that may require emergency medical treatment:

• Changes in, or unequal size of pupils
• Convulsions
• Distorted features of the face
• Fluid draining from nose, mouth, or ears (may be clear or bloody)
• Fracture in the skull or face, bruising of the face, swelling at the site of the injury, or scalp wound
• Impaired hearing, smell, taste, or vision
• Inability to move one or more limbs
• Irritability (especially in children), personality changes, or unusual behavior
• Loss of consciousness, confusion, or drowsiness
• Low breathing rate or drop in blood pressure
• Restlessness, clumsiness, or lack of coordination
• Severe headache
• Slurred speech or blurred vision
• Stiff neck or vomiting
• Symptoms improve, and then suddenly get worse (change in consciousness)

 COMPLICATIONS

Severe head injuries can cause serious complications. This is mainly because a serious injury to the head can potentially damage the brain, sometimes permanently.

In particularly severe cases, a serious head injury can result in death. This is why a condition will be closely monitored just after admittion to hospital. This will allow any complications that arise to be dealt with promptly and effectively. The following are the complications:

Infection: If the skull is fractured during a head injury, the risk of developing an infection may be increased. Skull fractures can occasionally tear the membrane. If this happens, bacteria can enter the wound and cause an infection.

Coma: A coma is where you are unconscious and unresponsive for a long time. Some people who have a severe head injury may enter a coma. Most comas only last a few days or weeks, but sometimes they can last for years. Many people recover from comas. However, in some severe cases, the patient never regains consciousness or goes into a vegetative state. A vegetative state is a situation where a person may seem to be awake and may show some limited physical response, but they have no awareness of their surroundings.

Brain injury: This can lead to a variety of complications. Some types of brain injury are only temporary, whereas others result in permanent damage. The effect of any brain injury will depend on:

• where on the head the injury occurs
• the type of injury, for example if the skull is fractured
• the severity of the injury, for example if it requires surgery

Physical effects: Difficulty moving or keeping your balance and loss of co-ordination. Headaches or increased tiredness can also be experienced. 

Hormonal effects: Damage to the pituitary gland may lead to the low production of hormones and as a result temper with homiostalsis.

Sensory effects: Senses may be affected by a head injury. The  sense of taste or smell may be lost. One would not be able to appreciate temperature changes in the environment or inside the body. Further facial palsy is due to injury to the facial cranial nerve.

Cognitive effects: Following a head injury, the ability to think, process information and solve problems may be affected. Memory problems are experienced, particularly with short-term memory, and have difficulty with speech and communication skills.

Emotional or behavioural effects: After a severe head injury, some patients experience feelings of irritation, anger or selfishness You may also laugh or cry more than before the injury.

 PREVENTION

There are many ways that Traumatic Head Injury can be prevented. Most of the measures are dependant on the individual to follow the guidelines.

• Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats.
• Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course.
• Be visible. Do not ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers.
• Use age-appropriate car seats or boosters for babies and young children.
• Make sure that children have a safe area in which to play.
• Supervise children of any age.
• Do not drink and drive, and do not allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.

 

MANAGEMENT

Treatment varies widely depending on the type and severity of injuries.

• Minor head injuries are often treated at home as long as someone is available to watch the person.
• Bed rest, fluids, and a mild pain reliever, may be prescribed. Ice may be applied to the scalp for pain relief and to decrease swelling.
• Cuts will be numbed with a medication usually given by injection. They will then be cleansed. Hidden injuries and foreign matter are looked for. The wound usually is closed with skin staples, stitches (sutures), or skin glue. Tetanus immunization will be updated if needed.

·         People with serious closed head injuries are almost always admitted to the hospital for observation and repeated studies to assure that the condition does not worsen.

Occasionally a head injury may cause elevated pressure within the skull. An intracranial pressure (ICP) monitor probe may be surgically inserted into the brain through the skull to measure the pressure. If the pressure rises too high, it may be necessary to do surgery to decompress the brain. Death is possible.

Intravenous medications may be used to control intracranial pressure as a temporizing measure until the crisis resolves or surgery is performed.

o   Medication to prevent seizures may be given to prevent or treat seizures that occur from the head injury. Seizures after head injury often do not require treatment because they may not reoccur.

o   Antibiotics are usually not required in closed head injuries. Some doctors use antibiotics in all cases of basilar skull fracture. Other doctors do not feel this is useful.

When there is a closed head injury with bleeding inside the skull, the doctor must consider a      number of factors to determine the correct treatment. Some of these include the location of the bleeding, severity of the symptoms, the presence of any other injuries, and progression of symptoms. Surgery may be needed. Other options include pressure monitors, medication to prevent seizures, and antibiotics to prevent infection. People with this type of injury may need a breathing tube inserted (intubation) to help prevent further brain injury. Angiography may be performed.  Penetrating head injuries often require some sort of surgery, usually to remove foreign material or to stop bleeding. Other options include pressure monitors, medication to prevent seizures, and antibiotics to prevent infection. People with this type of injury may need a breathing tube inserted. Angiography may be performed.