Head Trauma
It was a
typical warm summer night on Cleveland's near west side. Andrew was playing
after dinner with two friends that he called his buddies. He was biking
on his new mountain bike to Michael's house to see if he wanted to come
out and play. Andrew was full of summer energy, a great student who had
two weeks left of summer. Before his eyes at less than 10mph a 1997 pathfinder
pulled out of its driveway, the driver never seeing Andrew. At a mere
10mph and 15 feet away, all Andrew had time for was a scream and then
there was silence.
Twenty minutes later, EMS arrived in the Trauma Bay at one of the busiest
emergency departments in the midwest. The EMT had a breathing bag and
mask over Andrew's pre-pubertal face pushing air into his lungs that weren't
trying to breath on their own. He was strapped to a board with a plastic
collar around his neck. I proceeded to place a tube the size of his small
finger into his airway to breath for him since his chest wall didn't move
with out the nurse pushing the air into his lungs. Then I placed a large
needle into his thigh, slipped a wire through the needle and then a long
plastic catheter was threaded over the wire into Andrew's large vein,
dumping fluid into the right side of his heart. On examining Andrew, his
only findings beside his devastating neurologic status was a three-centimeter
bruise on the right side of his forehead.
His mom, Mary, a local school teacher and his Dad, Andrew Sr., arrived
still in their gardening clothes. I proceeded to tell them that Andrew
had sustained a severe injury to his brain, he appeared to have no other
injuries, first x-rays of his spine would be performed and then a CT scan
of his brain and abdomen would be done to further define his injuries.
Then, he would be placed on a ventilator in the pediatric intensive care
unit. Mary's eyes flooded with tears and as she wept she blamed herself
for not making Andrew wear his bike helmet.
Andrew's story occurs weekly at our trauma center and at many across the
country. His story doesn't end happy. His neurologic status improved slightly
to the point were his brain remembered to breath, but couldn't control
his own secretions, because he couldn't cough well. He had an incision
made in his neck and the tube was transferred to his neck called a tracheotomy.
Nurses could now insert a suction device down his trachea every hour to
suction out his normal secretions. Furthermore a plastic tube was inserted
through Andrew's skin into his stomach to feed him because his brain no
longer knew how to swallow.
This country is plagued by the problem of head injuries each year. 500,000
head injuries from mild to severe occur each year in this country. The
highest incidence occurs in patients with unprotected trauma with large
forces. Pedestrians and bicyclists struck have the greatest potential
for injury , while motorcyclists without helmets have the greatest potential
to become organ donors, hence the crude term, "donor cycles."
There are four main types of intracranial injury. The purpose of this
article is not only to make one aware of the types of head trauma, but
to remind you how simple measures can be taken to prevent this devastating
epidemic. In order to understand head trauma, one must first understand
the anatomy of the scalp, cranium and protective layers of the brain.
The scalp is actually made up of 7 layers but includes the hair, skin
and soft tissue layers. The skull is an extremely rigid structure of thick
bone that surrounds the brain on all sides except the exit of the brain
into the brainstem and spinal cord. Over the brain lie three layers, the
dura mata is coating over the brain, the arachanoid space and the epidural
layer is the most outside layer over the brain.
Cephalohematoma, a raised area on the scalp, occurs when a bruise or hematoma
occurs in the soft tissue outside of the cranium. These usually occur
when a patient is struck with an object or a patient hits there head gently
on an object. The swelling will resolve in 3 days to 2 weeks. Ice may
help the swelling. The only serious complication is an infected hematoma.
If the swelling worsens after day number 2 from injury, the swollen area
is warm, red or with drainage, it should be seen by a physician for possible
drainage and antibiotics.
Skull fractures can occur from a slightly higher force than that which
occurs in a cephalohematoma. Skull fractures in themselves are of little
worry, other than to rule out further intracranial injury. If a skull
fracture is displaced, meaning not laying in normal alignment some neurosurgeons
will opt to surgically fix them, especially if it is displaced towards
the brain.
Intracranial injuries include intracranial hematomas, epidural hematomas,
subdural hematomas and subarrachnoid bleeding. The final injury is Diffuse
Axonal injury. These five injuries can occur independently or in combination.
They each have characteristic presentations, treatments and outcomes.
Intracranial hematomas usually occur from large force injuries, which
result in blood within the brain tissue itself. These are often treated
non-operatively unless the pressure increases within the cranial vault
or the hematoma compresses part of the brain. Epidural hematomas usually
occur from a strike to the side of the head classically causing a brief
loss of consciousness followed by a period of wakened state, and then
a sustained loss of consciousness. This occurs due to build up of blood
with a shift of the brain contents from the blood outside the dural space
(ie epidural space). These injuries require prompt recognition by CT scan
and operative decompression within a few hours by a neurosurgeon after
rapid resuscitation by an emergency physician. This would include airway
control with intubation and fluid resuscitation to maintain blood pressure.
Subdural hematomas occur from bleeding of the bridging veins tearing below
the dural layer at the interface of the dura and brain. These can be acute
or chronic causes of mild to severe loss of consciousness. These are also
often repaired by draining the space by a neurosurgeon as soon as possible.
Finally subarrachnoid bleeding occurs in the in-between layer covering
the brain. This occurs both in traumatic injury and from ruptured aneurysms.
The treatment is complicated and ranges from conservative management to
tying off the aneurysm intraoperatively.
Diffuse axonal injury is the final common traumatic injury. This occurs
from a sheering of the nerves from an acceleration/deceleration mechanism.
The patient can have a devastating outcome from the subsequent swelling
that develops within the cranial vault.
All of these injuries have been proven to be preventable with some simple
measures. The medical literature has proven at length the benefits and
preventative effects of the simple wearing of helmets. It has been shown
that bicycle, motorcycle and ski helmets not only save lives, but prevent
patients from living in a chronic vegetative state like my patient Andrew.
Why is it that it is a requirement in some ski clubs for its members to
wear ski helmets - but throughout this town and state - bike helmets are not
required. Maybe it sounds strong but once you've had to tell people like
Andrew Sr. and Mary that their son Andrew will live his life without speaking,
smiling and only breathing and eating with the help of mechanical devices -
you will see how strong you feel.
Please Mom and Dad, make your kids wear their bike helmet every time, whether being cool riding down mainstreet at a mere 10mph or flying down bridal veil.
Thanks,
Robert Bessler M.D.
Visiting Resident Telluride medical center
Chief Resident
Department of Emergency Medicine
Metrohealth Medical Center
Cleveland Clinic Foundation
Cleveland Ohio
