
By Tedler D. Depaynos, MD
There was a time that the deaths in the United States due to head trauma exceeded the deaths due to the Vietnam War. And to think that there was a war going on and sophisticated weapons were being used to kill! The most common cause of head trauma was then vehicular accidents.
I am not updated on the statistics but in the Philippines with the worse traffic situation we have nowadays, death due to vehicular accidents is fairly common. It is often emphasized on TV and we read this almost daily in our newspapers. An obvious contributing factor is the proliferation of irresponsible and undisciplined motorcycle drivers who speed swerving left and right enjoying the wind and not caring for simple traffic rules. In one of our local hospitals, graduate surgical residents could recall that during their time at least one or more motorcycle accidents were brought into the emergency room weekly for treatment. Another factor is reckless driving under the influence of liquor. Many of the drivers involved in the accidents are with alcoholic breath and sometimes their voices and actions cannot be disciplined even in the emergency room.
Various injuries may be incurred like multiple fractures, severe body contusions, bleeding, lung injuries, etc., that may cause severe pain, difficulty of breathing, loss of consciousness or even death but we will limit our discussions to the anatomy of head injuries.
In treating head traumas, the layers of the head should always be taken into consideration in the analysis of injuries. External to the bony skull is the scalp and any injury to this layer is easily treated. There could be swelling or contusion, accumulation of blood clot or hematoma or bleeding due to laceration. For emergency control of bleeding, pressure is all that is needed and of course suturing eventually. Most of the time contusion and hematoma are just observed for with time they will subside.
Fractures of the skull may occur but again most of the time nothing is done especially if they are not exposed or open or not depressed compressing the brain. They may just imply the severity of the brain injury although in many instances, no fracture is seen but the brain incurred severe injury. This is usually a common mistake. Fractures are erroneously equated to brain injuries. Fractures maybe seen in x-rays but brain injuries cannot. They are determined clinically or by thorough physical examination of the attending physician. At present a CT scan which could reveal injuries to both skull and brain is routinely taken.
The brain is in a closed space limited by the bony skull. Jarring then of the brain itself when the head is traumatized may result in injury sometimes in both sides. The least serious is cerebral concussion where there is no anatomical injury. There is just a sudden physiologic cessation of function which would render the patient briefly unconscious. In an analogy, the current was cut off but the wires are still intact. This is what is experienced by boxers when they are knocked down unconscious but recovered quickly within 10 seconds. Depending on the force, some boxers will feel groggy for longer periods. As a rule, victims of cerebral concussions should not lose consciousness for more than 5 minutes. Nevertheless, these patients are admitted for at least 24 hours for observation.
In cerebral contusion, there is usually apparent loss of consciousness for more than 5 minutes and there is retrograde amnesia. These patients may not remember the events that occurred before they got unconscious. These are usually admitted for at least 72 hours for possible more serious injuries. There could be swelling of the brain tissues and destruction of brain cells. With time, the swelling will subside but if severe where the brain functions are compromised, supportive measures and medicines are administered to help the patient survive while waiting for the swelling to subside. In minor cases loss of function of certain brain cells may be taken over by the healthy ones and, luckily, humans have millions of brain cells. In other serious cases where massive brain cells are destroyed, resulting physical defects will be obvious. Brain cells without oxygen even within 3 minutes will necrose.
Worst scenario is bleeding within the skull. In general this is classified as bleeding above the dura called epidural or below the dura called subdural or within the brain tissues called intracerebral. The dura is a thick layer between the skull and the brain. Bleeding above the dura usually comes from the arteries and those below are from the veins. Hence the former is more acute because of fast bleeding while the latter is slow, chronic and insidious. With bleeding, accumulation of blood within the skull compresses the brain, the skull providing a non-expandable space with fast compression due to fast bleeding, the patient losses consciousness fast and if not relieved, the patient may expire. Hence, in these cases, surgical intervention is an emergency. Unlike in slow venous bleeding, brain compression may occur in days or even weeks or months so that loss of consciousness occurs after sometime when a sizable amount of brain tissues are compressed. This makes this entity insidious and sometimes the unconsciousness is thought to be due to other causes like brain tumors or even infections. When properly diagnosed, however, surgery also is a must.
Luckily, bleeding within the brain tissues in head trauma is usually due to small blood vessels. Since blood is admixed with the brain, it cannot be drained. Only in few instances where accumulation is large and drainage is needed. Hence, in most instances only supportive treatment is given. This may also be true in strokes but most of the time resulting hematomas are huge and need to be drained. Again depending on the extent of brain injury, the resulting physical disabilities may be minor or debilitating.
In summary, x-rays of the skull will only show a picture of the bones and not the brain. To know specific injuries to the brain, the CT scan which is practical and available in our local setting is a must and sometimes this is repeated to monitor the progress of the patient. Foremost, however, is a thorough examination, close observation and monitoring of the signs and symptoms of the patient.**