الفهرس 
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Abstract
Head injuries are a major cause of morbidity and mortality in the community. Brain damage after head injury can be classified by its time course. Primary damage and Secondary damage.
It is important to begin management of head injured patients from the scene of the accident to prevent secondary insults, once head injury had occurred, stabilization of patients with head injury begins at the site of accident by emergency medical personnel.
The brain is the greatly modified and enlarged anterior portion of the central nervous system which enclosed within the cranial cavity of the skull. The central nervous system (CNS) is enclosed in three connective tissue membranes, the meninges.
The cerebral hemispheres, located on the most superior part of the brain, are separated by the longitudinal fissure. The lower extension of the brain where it connects to the spinal cord.
Head injuries are commonly classified by a combination of cause, mechanism and consequences, both structural and functional. The two classifications of traumatic brain injury are primary injury and secondary injury.
Primary injuries are a result of acceleration-deceleration and rotational forces occurring at the time of impact. Injuries include lacerations, bone fractures, contusions, hematomas and diffuse axonal injuries.
Secondary injury following head trauma refer to all deleterious post traumatic events other than the actual mechanical brain lesion sustained at impact. Secondary brain damage may be divided into systemic and intracranial.
The mechanisms of traumatic brain injury and their clinical consequences is the foundation of the management of the head-injured patient, the extent of brain damage is determined by the severity of primary mechanical injury and intensity of secondary biomolecular injury.
The brain is damaged by one or both of two mechanisms through strains produced within the brain tissue itself and through differential movements between the brain and the skull.
History of trauma also should be obtained, severely injured patients are presented immediately unconscious due to irreversible brain damage.
General examination should be performed in all patients with head injury, in order to disclose other associated injuries (chest, abdomen...etc) vital signs (blood pressure, heart rate, temperature and respiratory rate) should be monitored.
Immediately following resuscitation and stabiliza-tion of vital signs, neurological examination remains the most important factor in rapid assessment of the extent and severity of cerebral injury.
The Glasgow coma scale (GCS) is applied based on best motor response, verbal response and eye opening. Level of consciousness is best assised using GCS the maximum score (15) and the minimum score (3).
Concussions are caused by impairment of reticular activating system, and there are typically no prominent sequel. Focal lesion include scalp laceration and skull fracture, epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage and penetrating head injuries (e.g. gunshot wound, implantation injuries).
Computed tomography scanning has become the primary imaging procedure in the evaluation of head-injured patients. Computed tomography is indicated in all unconscious patients, all patient showing clinical evidence of deteriorating level of consciousness, and all patients with fissure fractures or depressed over crossing dural vessels or sinuses.
The role of skull films in the evaluation of head injury has become less important with the advent of computed tomography scan.
Many studies have shown that MRI is more sensitive than computed tomography for detecting brain contusion and oedema.
The efficiency of any trauma center to optimize care of multiple injured patients, depends on the following, early resuscitation and stabilization either at the scene of the accident or in the hospital, rapid transportation of the victim to an appropriate trauma care-facility.
In acute airway obstruction, apnea or hypoxia, an open airway is mandatory to life and must be provided at once. Orotracheal intubation is best avoided, manual stabilization of the cervical spine is necessary during procedure. Nasotracheal intubation may be safer than orotracheal intubation with manual stabilization.
After an airway is established, breathing or ventilation must be assured by auscultation of both lung fields for main stem bronchial intubation.
The best method of mechanical ventilation is volume ventilation under positive pressure. Secure the airway (usually by endotracheal intubation) in patients with GCS ≤ 8 who are unable to maintain their airway or who remain hypoxic despite supplemental O2 need for hyperventilation.
IV fluid infusion continues with balanced crystalloid solution. Avoid hypotonic fluids which lead to decrease serum osmolarity and sodium levels which increase brain oedema. Triple-lumen central venous catheter is inserted by subclavian vein puncture, which allow both volume infusion and central venous pressure monitoring.
Foley’s catheter is placed to evaluate urine output, control of hypertension is achieved by the use of trimataphan camsylate. Monitoring of cardiovascular and fluid status requires arterial line, CVP line.
Management of intracranial hypertension is indicated in patients with severe head injury with GCS £ 8, with normal or even abnormal CT scan of the brain.
Early surgery to reduce risk of infection, elevation and debridement are recommended if there is no evidence of wound infection primary bone replace-ment, antibiotics should be used for all compound depressed fractures. However in most cases EDH is a surgical condition. Treatment of acute subdural hematoma is a true emergency if the lesion is greater than 5mm in thickness. It is not always necessary or advisable to evacuate an intracerebral hematoma.
Outcome prediction after severe head injury to be an area of intense interest.
Patients with coma of 6 to 24 hours associated with diffuse injury had a good recovery, diffuse injury with coma lasting longer than 24 hours carried a poor prognosis.
As death is the most frequent in child who present with flaccidity and fixed and dilated pupils. Patients with GCS of 3 and bilateral fixed dilated people (BFDP) in the filed should be resuscitated aggressively, especially if the trauma seen to be not too severe.
Finally, a better understanding of the factors associated with good or bad outcomes are useful in determining management strategies to gain optimal results.