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20 Ellul 5762 - August 28, 2002 | Mordecai Plaut, director Published Weekly
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Home and Family
Your Medical Questions Answered!
by Joseph B. Leibman, MD

Diplomate, Board Certification of Emergency Medicine

Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua Hospital

Continuing from last week about head injuries.

A person who has sustained a head injury and who is unconscious, should be transferred to the hospital. It is important to be accurate about how long the person was out, as this will affect how we treat the patient. Head injured patients can have skull fractures, bleeding around the brain (this is called epidural hemorrhage), bleeding within the brain (in trauma usually a subdural hemorrhage), and diffuse axonal injury, which is injury to a large part of the brain, without bleeding. We'll discuss each one.

Skull fractures do not necessarily indicate danger. A small linear fracture of the skull requires no therapy and does well. Therefore, we don't x-ray skulls anymore; we proceed right to CT if indicated, as bleeding is more important. Skull fractures that have depressed into the brain, open skull fractures, and fractures at the base of the brain are all much more serious.

Bleeding is much more serious. The brain is a very important organ and as such has a rich blood supply. It is encased in a rigid container called the skull which protects it, but does not give much room for swelling. Intense bleeding will swell up the brain and if it compresses too much, the brain -- and person lo oleinu -- will die. This is indeed why few people survive gun shots to the head: the bullet is unlikely to miss a major blood vessel somewhere in the head, and the bleeding that follows is fatal.

Epidural bleeds are always dangerous, are always associated with skull fracture and almost always need an operation. Subdurals can bleed at a slower rate. Therefore there can be an acute subdural and a subacute, the latter only manifesting around two weeks or so after the injury. Subdurals often need surgery as well, although all surgery on the brain is treacherous, and old people do poorly with it. Death or chronic disability are not uncommon.

Diffuse axonal injury show CTs that are generally unremarkable except for some swelling. These people may not be responsive, and if you have heard of people waking up after a long period of unresponsiveness after major trauma to the head, it is usually these people. Keep in mind that the brain needs a lot of blood as we have said, and lack of delivery of blood or oxygen to the brain for whatever reason can lead to brain death. These people can be in a vegetative state indefinitely. These people generally do not wake up.

We will speak on how we evaluate people for these injuries next week but I would like to tell you a little story -- a true one that speaks for itself. About 15 years ago a man in his sixties was flying over the Sahara desert and the plane crashed. All perished except for this older man. Since the Sahara is so big, the plane could not be located and it was only after help from US satellites that the plane was discovered and the man taken to the hospital.

Two weeks later, it was discovered that he had a subdural and he was taken to surgery in Jordan, where the neurosurgeons are of poor quality. Nevertheless, he survived. That man is Yasser Arafat. Write me in care of the Yated.

A message from Glaxo, sponsor of this column. Headache. Once again another study has come out lauding the triptans for migraines, and Imitrex was the first in this group. It has passed the test of time for effectiveness and safety. I think it is worth the expense. I have taken it myself, and am impressed with how it worked.

 

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