Head Injury
Head Injury
By Dr. Ravindra Patil
Head Injury – Traumatic Brain Injury
Much has been written about the golden hour in treating grievous head injuries. The earlier the treatment is begun, the better the outcome. But in real life, the scenario is totally different. People do not rush to the hospital, they wait and take opinions, and they hope things will become better.
I share a real case that we treated at Samarth Neuro Hospital. The patient survived without any neurological deficit, but just!
But let us first see what happens when there is a violent impact on the head.
Table of Contents
Results of head injury
Any impact on the head is a head injury. A head injury causes many sudden changes in and around our brain.
The first cause is the direct injury and any part of the brain that might sustain the impact and be injured.
The second cause is the contrapuntal [or Contrecoup] brain injury. These injuries affect the side of the brain opposite of where the impact of the head injury occurred. They are often overlooked or misdiagnosed because of their location on the opposite side of the brain. Contrecoup occurs when a force or blow causes the brain to strike the side of the skull opposite from the point of impact. This happens because the brain is floating inside the skull and its covers membranes in the cerebrospinal fluid.
As a result of head injuries, blood vessels of the brain may be ruptured. They bleed. As the skull and the brain within are tightly enclosed, any bleeding increases the pressure around the blood. A collection of blood in the brain [called a haematoma] may press vital areas of the brain and cause functional disorders which are reversible once the blood collection or haematoma is drained.
Any injury increases the pressure of the liquid around the brain [this liquid is called the cerebrospinal fluid or CSF]. This liquid usually helps dampen shocks to the head. But if the CSF pressure increases, it is dangerous for the brain, which is made of very soft and delicate nerve fibers and fat. Symptoms of increased CSF pressure are headache, nausea, vomiting and severe discomfort. The pupils may not react to light. High pressure may rarely push a part of the brain into the canal of the spinal column. This is called ‘herniation’.
A real life scenario
All names in this real story have been changed.
10 month old baby boy Sujay was playing peacefully in his crib. His loving seven year old sister Saumya picked him up and Sujay laughed happily. Just then the phone rang. Saumya wanted to take the call and hand over the phone to her mother because she liked to answer phones. So she rushed to the phone. She held Sujay in one arm and climbed a three feet high bed to reach the top of the cupboard to pick up the phone. During that childish attempt, she lost her grip on baby Sujay and the poor fellow slipped out of her arm fell on the ground with a bang. The height from which Sujay fell was estimated to be five feet. Saumya shrieked in panic. Their mother rushed in and was about to scold Saumya for climbing on the bed when Saumya pointed to Sujay lying on the floor.
The baby was motionless.
Saumya and Sujal’s mother Rashi’s first reaction was that her lovely baby had died!
She collapsed to the ground next to her baby in shock, a silent spectator to her baby’s death. Saumya kept on screaming and her screaming brought their neighbours to their house.
They lived in a small town near Sangli. It was getting dark. The neighbours crowded to see the baby lying on the floor motionless. Then one lady gently picked up the baby and held it in her lap. The lady held small cotton fibres in front of the baby’s nose. The fibres moved. So the baby was breathing and alive! Thank God!
Rashi was still in a shock. So the neighbours sent someone to call in their family doctor. The doctor was busy with his patients, yet he came to see baby Sujay after half an hour.
Note how time delays occur in real life scenarios. When the doctor actually examined the baby, one hour had passed.
The doctor gently examined Sujal’s head and found that there was a depression on the left side of the baby’s head. Also, the fontanelle was bulging outwards and upwards.
Fontanelles
The fontanelles are the soft spots on an infant’s head where the bony plates that make up the skull have not yet fused together. It is normal for infants to have these soft spots, which can be seen and felt on the top and back of the head. There are two fontanelles. The fontanelle near the back of the head usually closes by age 1 or 2 months. While the fontanelle on the top of the head usually closes sometime between 9 months and 18 months. The fontanelles help the skull expand as the brain grows and develops. If the intracranial CSF pressure increases, the fontanelles bulge out. That is what had happened in Sujay’s case.
In adult patients there are no such fontanelles and nothing bulges out.
The doctor guessed that it was a serious condition. He talked to Sujay’s father on phone and advised that Sujay be taken to a brain specialist immediately. Sujay needed a brain CT scan and perhaps surgery.
The doctor did not administer any medicine, saying it could be dangerous.
Now the family was in a dilemma. What were they to do?
Was the doctor right? Did the baby really require immediate surgery? Would the swelling on the head go away on its own? How could such a small baby be operated? And how could they take the baby to the hospital so late in the evening? By then it was 9 PM.
Rashi had recovered her wits. She gently took Sujay in her lap and talked to him. He responded by crying. Till then he was not responding. He only breathed.
Rashi tried feeding the baby to stop its crying, but the baby did not feed. Instead, it vomited. Curd like milk came out in its vomit.
The family contacted their relatives in Pune and Mumbai. Someone suggested immediate transfer to Mumbai or Pune. Others said it would take too much time.
Samarth Hospital
“What about that hospital on Sangli Miraj road?” Someone asked.
“It must be closed…”
“But it is open for 24 hours…”
Finally against Rashi’s wishes and with not much hopes that the baby would survive, Sujay was brought to Samarth hospital.
Rapid response
The Emergency Room [ER] staff immediately called a neurosurgeon and a paediatrician. Till the specialists came, the nurses and duty doctors had examined the patient’s vital signs and reported them to the surgeon, who immediately ordered a CT scan.
Sujay was sedated so that he would lie still. Then the CT scan was done.
The surgeon and paediatrician checked the CT scan. A huge subdural haematoma was seen on the CT scan.
“Requires immediate decompression as there is a midline shift,” the surgeon said.
“But let me first do pre-operative examination and let us make the baby NBM.” The paediatrician said. NBM in doctors’ slang is ‘Nil by mouth’. Prior to anaesthesia, all patients are made NBM.
It was 11 PM. The baby had to remain NBM for at least six hours before anaesthesia could be given.
The surgeon ordered the operation theatre [OT] staff to be ready at 4 PM.
OT preparation
Preparing the OT for brain surgery does not mean just switching on the lights and the air conditioner. It requires hundreds of sterilised instruments, medicines, anaesthesia trolley, skilled surgeons, scrub nurses, OT technicians, OT runners and so on. Every person must wear OT scrub suits. The surgeons and scrub nurses wear sterilised gowns over their scrub suits. Finally they wear caps, masks and lastly the sterile gloves.
OT consent
The surgeon explained that the surgery was dangerous. However if successful the life of the baby would be saved.
“Will he be completely normal?” Rashi asked, sobbing. The surgeon explained what the risks were. The parents gave their consent and the anaesthetist began his work.
Decompression surgery was done on the little baby. The haematoma was drained. The pressure on the brain was released.
After surgery, Sujay was drowsy for a long time. Then gradually he opened his mouth. The first thing he tried was to pull off the bandage on his head. Then he cried.
In the next 24 hours Sujay was breast feeding. His intravenous liquids were stopped.
On the second day after surgery he was sitting upright on the hospital cot and smiling at the doctors.
He was discharged in a four days. His sutures were removed after a week. He is expected to heal completely and grow normally without any permanent brain deformity.
Analysis
Babies fall often, but mostly they recover. Surgeries on babies are more difficult than adults. They require more skills and experience. Treating head injuries in a babies is even more complicated. However, the team of medical and paramedical professionals at Samarth Neuro Hospital manage such cases with skill, confidence and good outcomes.
If Sujay had been brought to us the next day, it would have been too late and the outcome of surgery may not have been so good.