THE EARLY TREATMENT OF THE HEAD-INJURED PATIENT

The most important consideration where there is some desrcc of unconsciousness in a patient with a head-injury. is to KEEP T H E AIRW AY FREE. Tnc brain receives nearly 20'., of the total cardiac output of the body, and if" the airway is obstructed, the increased CO, increases the blood volume within the skull due to vasodilatation. This has the elfect of raising intracranial pressure, with secondary compression and death of many brain cells and resultant permanent brain damage. Shis may occur very rapidly, even in a period of only \ few hours. Where there is ccrebral oedema or any other cause of increased pressure within the cranium, such as a subdural haematoma. or tumour, the skull itself cannot, of course, expand, so that the pressure is exerted downwards and centrally towards the ten­ torial notch and brainstem. Here, where there arc thousands of fibres converging on a very small area, a great deal of damage can be done, giving rise to pres­ sure on one or more cranial nerves, varying degrees of spasticity, hemiplegia and so on. The recticular forma­ tion can also be damaged, with resultant further depres­ sion of the conscious level.

The most im portant consideration where there is some desrcc of unconsciousness in a patient with a headinjury. is to K E E P T H E A IR W A Y FREE. T nc brain receives nearly 20'., of the total cardiac output of the body, and if" the airway is obstructed, the increased CO, increases the blood volume within the skull due to vasodilatation. This has the elfect of raising intracranial pressure, with secondary compression and death of many brain cells and resultant perm anent brain damage. Shis may occur very rapidly, even in a period of only \ few hours. Where there is ccrebral oedem a or any other cause of increased pressure within the cranium, such as a subdural haem atom a. or tum our, the skull itself cannot, of course, expand, so that the pressure is exerted downwards and centrally towards the ten torial notch and brainstem. Here, where there arc thousands of fibres converging on a very small area, a great deal of dam age can be done, giving rise to pres sure on one or m ore cranial nerves, varying degrees of spasticity, hemiplegia and so on. The recticular form a tion can also be damaged, with resultant further depres sion of the conscious level.
Degrees of C onsciousness: 1. The patient may be drowsy, but can easily be mused and can give a good account in terms of name, place, time, etc. 2. Disorientated, but still able to tell the stall his name and address. 3. Only a grunt, but at least an attem pt at a verbal response! W hen there is no longer any verbal response, a painful stimulus can be produced by rubbing the patient's sternum firmly with the knucklc. This may then give rise to the following reactions:-4. The patient will attem pt to push away the hand with both of his in a purposeful m anner. It can also be noted at this juncture whether there is ;i complete or partially paralysed arm. 5. The patient extends his legs, flexes his elbows, and clenches his fists. This is known as the decorticate posture, probably indicating that the cortex is not responding, only the brain stem and diencephalon.
(See illustration No. I.) 6. The patient extends and internally rotates his arms and extends his legs. This is the decerebrate posture, probably indicating that the brain stem alone con trols the patient's reactions, and the outlook is more serious. (See illustration N o. 2.) 7. The patient is in a coma, with complete lack of response to any stimulus, the limbs are flaccid and the outlook is grave. Patients, if adequately nursed, can remain for months, or even years, w ithout regaining consciousness in any of the states described, in 5, 6, and 7.

Observations:
Because the patient's condition can alter so rapidly, it is extremely im portant that during daily treatm ent accurate observations are made by the physiotherapist of the patient's reactions, and any deterioration im mediately reported to the doctor. There are two condi tions in pailicuJar that call for urgent action: -! Further deterioration of consciousncss. indicating or increasing intracranial pressure, with cerebral shift and brain stem compression.

2,
A sluggishly reacting or completely fixed pupil to light, showing that the 3rd cranial nerve (oculo m otor) has also become involved at the tentorial notch.
D egrees o f Paralysis: I. Monoparesis, one limb only involved, usually the arm. If the face and leg on that side are not para lysed one must suspect a local injury such as a brachial plexus lesion.   always have a hemiplegia on his rig lu side, as would occur with a case of CVA. In one out of five cases the paralysis is on (he same side as the compressing surface haem atom a. This is because the expanding lesion on the one side will cause a brain shift to the opposite side so that the opposite cerebral peduncle will be compressed by the edge of the tentorium cerebelli, thus paralysing fibres which will decussatc to the limbs on the side of the expanding lesion.

A, Flacid hemiplegia. B, Spastic hemiplegia.
4. Paraplegia -Paralysis of both legs usually seen with spinal injuries but rarely also with certain intraccrebral lesions at the vertex.

Tetraplegia
-Paralysis of all four limbs, usually indicating high cervical spinal cord injury. Tipping: Any unconscious patient who has secretions in his chest, has the foot of the bed raised seven inches to assure continuous slight drainage. This height does not constitute postural drainage for treatment of the chest; the bed can be further elevated if that is required. It does, however, ensure that the secretions from the trachea flow freely into the mouth. W hen the patient is lying in a hospital bed with a sagging mattress, the secretions tend to remain in the chest and produce respiratory complications very easily. It might be thought that the oedema within the head would increase by continuous tipping, but an obstructed airway will produce a much greater increase in intracranial pressure. In cases of assault, there is often e x te r n a l oedema and here one hesitates to tip except for the duration of a specific chest treatment. It is also unwise to tip obese patients due to the increased effort required to move the heavy abdom inal contents pressing upwards against the diaphragm.
T h e im p o rtan ce o f suctioning: W here there has been a brain-stem lesion, or very low level of consciousness, the cough reflex is sometimes depressed or absent. In addition, no unconscious im mobile patient coughs without external stimulation. Hencc it is absolutely essential to assess whether the patient has any secretions by stimulating him to cough. Passing a moistened suction catheter gently down the patient's pharynx via his nose, usually suffices. If the cough is non-productive, if he is being turned at twohourly intervals, and no anaesthetic has been given, the chest should remain clear. A quick daily check is, how ever, neccsssary and a routine chest treatm ent carried out after any operation. D o n o t suction through the nose if there has been much bleeding from it, or where cerebrospinal fluid is leaking from the nose.

T u rn in g :
T he patient is turned from side to side by the nurses every two hours. A pillow is placed at his back to keep him so. and where there is any paralysis of the lower limbs a pillow is placed between the knees. If he is very restless, he may be found lying on his back, but this is n o t a good position for the unconscious patient as the jaw and tongue will drop back and block his airway. Rather use a bolster under one side of the mattress, and pad the cotsides with pillows so that he remains on his side, preferably slightly prone. Light handcuffs m ade of foam rubber and Velcro frequently have to be used in this type of case to prevent the pulling out of Ryles tubing, drips, etc. P hy sio th erap y T rea tm e n t: M ost head-injuiies fall into one of three main cate gories: (a) T he minor injury, such as the semi-conscious patient with a depressed fracture or haem atom a, who recovers full consciousness within a few hours or days; (b) T he patient who remains unconscious for several weeks, has had a tracheostom y performed, and has probably a mild degree of spastic hemiplegia; (c) The severe brain-stem lesion, the patient with a tracheostomy, and decorticate or decerebrate re actions and considerable generalised spasm. AH the above may occur in a patient with multiple injuries such as limb fractures, haem athorax. or visceral injury, in which case the treatment would have to be adjusted accordingly. T he following suggested treat ments are for the head-injury only.

I. T H E M IN O R IN JU R Y :
(a) Chest routine as considered earlier.
(b) Check all limbs to see if there is any weakness.
A painful stimulus on the muscles will produce irritable m ovem ents and make obvious any hem i plegia. Passive movements are then given for it. with daily verbal and active attem pts to stimulate the patient to move the limbs. Recovery with this type of case is usually rapid and uneventful.

T H E M O R E S E V E R E IN J U R Y :
T he basic treatm ent is the same, but m ore attention m ust be given to keeping the chest clear. T he patient may have no active m ovem ent except for extensor spasm in one arm and leg at the slightest external stimulus. As the cerebral lesions and his general condition im prove, spontaneous m ovem ents of his norm al limbs will be tne first to return.
T o do passive m ovem ents on the affected side, the extensor spasm in the leg can usually be relaxed by slightly abducting and internally rotating the hip, then firmly flexing the toes and bending the knee at the same time. If the spasm still persists, do not force the movement, but shake and roll the limb before repeating the procedure. Tne ankle can best be dorsi-flexed whilst the knee is bent. Holding the foot firmly in that posi tion, slowly straighten the knee to obtain the fullest stretch. T he spasm of the Achilles tendon, which can be very severe at times, improves rapidly as conscious ness is regained, and no splinting or sandbags have been found necessary. Passive m ovem ents done several times a day seem to produce the best results. Once the patient is standing, the spasm relaxes and the weight of the body stretches the last few degrees of the range.
The extensor spasm in the arm can, after a week or so, evolve into a flexor spasm of the elbow, which m ay prove difficult to cope with. T he shoulder should be mobilised gently because of the danger of a frozen shoulder due to capsular tearing. A bduct and externally rotate the arm and while elevating it, slightly shake and gradually stretch it at the elbow. W here resistence is felt, bring the arm down again and repeat the whole process until you have obtained as great a range of m ovem ent as possible w ithout forcing. Finally, mobilise wrist and fingers in the elevated position.
Providing the patient's tem perature and BP is normal, and he seems to be improving in his reactions, he can gradually be sat up, first in bed, and within a day or two, out in a chair, with head and arm s firmly sup ported. If circumstances permit, he can be put in a cold bath daily by the nursing staff, even with the tracheo stomy tube still in situ. T he stimulation produced by cold water and sitting up, improves the conscious state rapidly. At this stage, a response to com m and m ay be forthcoming. A t the request: "Squeeze my han d " , one m ay feel a slight grip, which indicates that although the patient m ay not seem aw ake or registering anything going on about him, and is not attem pting to vocalise, he can at least hear and com prehend.
N ow the rehabilitation program m e can commence. T he patient m ay be confused and m ay only react to a few com m ands at first, but with constant stimulus of movement and the physiotherapist's voice, im provement can be rapid. M at routine should be started, with p ar ticular attention to head control and balance. T o begin with one has to p u t the patient into the desired posi tions, e.g. with the patient in supine, lift and turn his head to encourage him to roll; raise his hips in bridg ing. Roll him into prone-lying, rem em bering that if he still has a tracheostom y, a pillow m ust be put under his chest. Place his elbows under his shoulders with his hands forwards, and encourage him to lift his head. Brisk stim ulation of the trapezius muscle and assistance in raising the head may well produce co-operation from the patient even if he cannot hold his head up for long. This might suffice for the first mat treatm ent as he is often only semi-conscious at this stage. N ext day try sitting .the patient up from side-lying, leaning on one elbow or the outstretched arm, or putting him into four point kneeling. A second person's help m ay be needed here, to allow one to concentrate on a possible hemiplegia arm. Encourage the triceps by skin stim ula tion and give further constant reminders to the patient to keep his head up. Put him into long sitting, leaning back on his hands and you may find him pushing him self forward along the mat. If he resists long-sitting, let him sit cross-legged, as balance is easier in that position. All the time one tries to make the patient use his own balancing mechanisms and to regain some of his postural body-righting reflexes. Even a semi-conscious patient with minimal paresis, when put into four point kneeling has been known to attem pt to get him self to his feet w ithout any com m ands being given, and attem pt to walk with the assistance of the physiothera pist. One should not have any fixed ideas on treatment, Fig. 3. T h e feet o f a p a tie n t w ith a long-term brain stem injury. and one has to "play it by ear" a good deal of the time, as no two cases are the same. Only when the patient is fully conscious, can one begin any strengthening exercises. It is then also that one can encourage attempts to speak, and give him pen and paper to see if he can write his name, and so on. At this stage, the help of the speech therapist can be enlisted. 3.

S E V E R E B R A 1N -ST E M IN J U R Y :
The basic treatment is as before, keeping the chest clear, and mobilising the patient as m uch as possible. M any brain-stern injured, however, have gross spasticity and maintain it for many m onths, with no spontaneous m ovement. One can only attem pt to keep the patient mobile in the hope that he will eventually regain con sciousness, with minimal fixed contractures. It has been found th a t w h e th er th e p a tie n t is in side-lying o r supine, a sandbag placed so th a t the head is flexed fo rw a rd a little, can som etim es relieve th e spasm . W hen h e has been tu rn ed in to prone-lying, leave him f o r a sh o rt time w ith his arm s u p a b o v e his head. W h ere th ere is a very spastic h ip o r knee, brin g the p a tie n t in supine to the edge o f the b e d a n d in a d d itio n to a shaking o f the leg and a b d u ctio n o f th e hip, b en d the knee over the edge of the bed a s th e toes are flexed. P la ce the leg back o n th e bed w ith th e knee still b e n t and slow ly increase h ip flexion. T his, in tu rn , increases the knee flexion, b u t the full range m ay be im possible. T h e lo n g term case w ith th e tig h t A chilles ten d o n is a g re at p r o b lem (See illu stra tio n N o . 3). If th is type o f p a tie n t starts to w alk, a ten d o n lengthening o p e ratio n m ay have to be done despite all o n e 's efforts. I t is n o t sufficient just to m obilse the lim bs. R o tate the h ead ; m obilise the shoulder-blades; ro ta te th e tru n k w hen th e p a tie n t is on his side, or, if th e legs are n o t to o stiff, use one as a fulcrum fo r ro ta tin g the tru n k w hen supine.
-Finally, re m e m b e r in all cases:-W hen tipping a p a tie n t fo r ch est drain ag e and som eone else has to b e a tte n d ed to, p u ll b a ck the curtains so th a t the p a tie n t is u n d e r c o n stan t surveilance. N o head -in ju red p a tie n t sh o u ld b e left alone beh in d c u rtain s, as he m ay o b stru c t his a ir way o r have a se izu re w ith o u t a n y b o d y being a t hand. It is im p o rta n t th a t the fit c an be seen b y any staff th ere, a n d th a t its fe atu res b e n o ted : w h e th er occurring ju st in the face, o r w h e th er the arm and leg are also involved, a n d the exact tim e it lasts.
If one w itnesses a fit, it sh o u ld alw ays be re p o rte d to th e sister im m ediately. 2.
R eplace cotsides o n the bed. A h e ad -in ju re d p a tie n t is som etim es c o n fu sed a n d v ery restless a n d m ay fall o u t o f bed repeatedly. 3. It is n o t alw ays possible to exactly lo ca te th e b rain lesion, a n d w ith som e in ju ries th e p a tie n t is able to tak e in w h a t is being sa id a ro u n d him even th o u g h he is q u ite u n ab le to indicate this. T h e re fore, o n e sh o u ld b e very c a re fu l o f w h a t is said. A n y d esp o n d e n t sta te m en t can be left u n sa id u n til later. 4. T h e u n co n scio u s p a tie n t leads a very lo n ely life, so ta lk to him . By so doing, one stim u lates his m en tal activity and th a t is a very im p o rta n t p a r t o f th e to ta l head in ju ry trea tm e n t, a n d one c an n o t begin to o early . F in d o u t th ro u g h a re la tiv e w h a t the p a tie n t's h om e language is, because even if he could speak several languages previously, he will respond best a t first to his native tongue. In c ertain p a rts o f th e w orld, this can involve th e p h y sio th era p ist in co n sid erab le linguistic difficulties, b u t it is alw ays w o rth the attem pt!

A C K N O W L E D G E M E N T S
I w o u ld lik e to th a n k P ro fesso r 3. C. d e Villiers, C h ie f C o n su lta n t, N eu ro -S u rg ica l U n it, G ro o te S ch u u r H ospital, very m u c h for. his h e lp in preparing this article, a n d f o r th e len d o f h is p h o to g ra p h s. In addition, th a n ks g o to M iss H e b ler fo r the typ in g o f th is article.