Head injuries are the major cause of mortality and morbidity especially following road traffic accidents. Care of head injured patients forms an important part of a neurosurgeons and a trauma surgeons work in all parts of the world. With increasing industrialization and more rapid means of transport the incidence of head injuries is increasing steadily. In more developed countries with fast moving traffic, head injuries are more severe and often associated with multiple injuries. In India there is a combination of fast and slow moving traffic, with traffic indiscipline and chaos a significant contributory factor. India’s fatality rate of 55 deaths per 10000 vehicles is amongst the highest in the world. Besides the number of deaths caused, head injuries are a major social problem due to the loss of young intelligent minds to trauma, a loss of man hours at work resulting in an increased burden to society and family. The only way to avoid this great social tragedy, is to find ways to prevent head injuries. Greater road discipline and the enforcement of traffic laws, public education of the fallout of major trauma, better on site medical and para-medical care with an efficient ambulance and first aid will go a long way in reducing the incidence and severity of head injuries. Two factors which will go a long way in the prevention of major head trauma are the compulsory wearing of helmets when riding or sitting pillion on two wheelers and the strict avoidance of driving after consumption of alcohol.

The final result of a head trauma is the cumulative effect of different forces acting on the head and the differential transmission of energy waves through the skull and the brain. The skull is a rigid hard container, that holds within it the soft jelly like brain. Between the two are the coverings of the brain, blood vessels and within the brain are the fluid filled ventricles. When a moving object hits the head, or when a moving head hits a stationary object, there are two mechanisms that are set into motion that result in brain damage. The first is the differential deceleration between the skull and the brain. The skull stops moving when it strikes a stationary object, while the brain continues to move forwards. This results in the brain hitting against the uneven and jagged surfaces of the inner surface of the skull base, resulting in injury to the brain. The greater the momentum with which the head strikes an object, the greater will be the differential deceleration and injury. The second mechanism is the force of impact, which is dissipated through the skull to the brain. Depending on the severity of the impact, a lesser or greater force is delivered to the skull. This force is then transmitted as energy waves through the bone and the brain, resulting in fractures, heamorrhage etc. The wearing of a crash helmet is aimed at reducing the impact force that reaches the brain, therefore lessening the actual brain injury.

PRINCIPLES OF MANAGEMENT

The management f a head injured patient is in multiple stages:

• On site and immediate steps
• Transportation
• Definitive treatment

Onsite Management and Immediate Steps

The main objectives of management at the site of trauma are to establish the following: Airway, Breathing and Circulation or the ABC of acute care. These are of extreme importance as making sure of proper airway, breathing and circulation ensures that there is proper oxygenation of blood and that the circulation is good so that cerebral oxygenation is good. When these basic parameters are not taken care of at the site of injury, the patient often suffers a “second accident” resulting from hypoxia to the brain. The scalp is an extremely vascular structure and lacerations over the face and head often bleed tremendously. Bedsides the vessels of the scalp lie in the sub- aponeurotic layer, such that the arteries are held open even when there is a cut. Pressure over the edges of the scalp laceration or eversion of the scalp after the application of forceps on the galea will stop any bleeding immediately. Similarly any cut or laceration anywhere else in the body should be looked for and the bleeding should be stopped, at least temporarily, by appropriately placed tourniquets and , or pressure dressings. Once the ABC are looked at and ensured, the next step is to stabilize the patient for transportation to the hospital. The conscious level of the patient is to be noted and any obvious bleeding is to be controlled with pressure bandages.

Approximately thirty percent of all major poly and head trauma are associated with injury to the cervical spine. In all cases of trauma it must be assumed that the patient has suffered a cervical spine injury until it is proved negative. This means that the patient should not be immediately bundles into any available vehicle in any manner possible. A cervical collar or support and a backboard are mandatory. These will ensure that during shifting there is no inadvertent movement of the cervical spine, preventing a disaster. If the ideal collar or backboard is not available on site, one can use any available material temporarily so that the purpose of splinting the spine is served.

At the hospital, the team experienced in the management of head injury and poly trauma takes over the care of the patient. Once again it is important that the patient is first stabilized before anything else is done. Once stabilized, the conscious level and pupillary reaction are looked for, as well as the presence or absence of long bone fractures, and abdominal rigidity. As a protocol, there should be radiological screening of the entire spine, a non- contrast CT scan of the brain and ultrasound of the abdomen performed for all cases of poly trauma. The anesthetist, neurosurgeon, general surgeon and orthopedic surgeon form the trauma team and assess the extent of injuries, and formulate the plan of action for each case.

Indications for Neurosurgical intervention in a case of head injury include deteriorating conscious level and, or, papillary dilatation associated with an intracranial hematoma (extradural or subdural), cerebral contusion, or cerebellar hematomas. Diffuse cerebral edema often associated with multiple petechial hemorrhages all over the brain are best treated with anti-edema measures and ventilation with paralysis. Steroids have no role in the management of head injuries. Ventilation with paralysis works by reduction of the carbon dioxide content of the blood (PaCO2), which controls cerebral blood flow. The aim of ventilation is to keep the PaCO2 at about 25-30 mm Hg for the first 48 hours and then slowly bring it to normocarbia (40 mm Hg) after that.

The best way of management of head injuries is to prevent them. Enforcing traffic discipline is the best way of doing this. Crash helmets have to be made compulsory for all riders and those sitting pillion on two wheelers (whatever the type). Similarly seat belts should be worn in all cars. Social awareness of the cost involved in the management and waste of precious life associated with head injuries must be increased. Society has a duty to perform if young productive lives have to be saved from the clutches of head injuries.