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.
