Head injuries are considered the most dangerous in traumatology, because even minor brain damage is fraught with serious consequences that are incompatible with life. Varieties of traumatization are described in the document of the International Classification of Diseases, 10th revision, under certain codes, so the traumatic brain injury code according to ICD 10 looks like E-008.
The various versions of possible pathologies included in this protocol have their own personal code, which greatly facilitates the work of traumatologists, resuscitators and neurosurgeons. The goal of this block throughout the world is to restore and maintain the functioning of all vital organs and systems.
Local protocols in diagnosis, treatment, and prognosis of the course of post-traumatic pathology determine the actions of specialists.
Class XIX - Injuries, poisoning and certain other consequences of external causes (S00-T98)
This class uses specific letters to code different types of injuries . S is often used to code injuries to a specific part of the body, but the letter T is used to code multiple injuries to individual unspecified parts of the body. It is also customary to use this letter to encrypt poisoning and some other consequences of exposure to external factors.
Each damage component should be coded separately.
ICD-10 codes S00-S09 - head injuries
Experts include the following damage in this block of ICD codes:
- S00 superficial head injury;
S01 open head injury;- S02 fractures of the skull and facial bones;
- S03 dislocations, sprains and damage to joints;
- S04 disturbances in the functioning of cranial nerves;
- S05 damage to the eyes and orbits;
- S06 intracranial injury;
- S07 crushed skull;
- S08 amputation of part of the head;
- S09 other bruises.
It is worth noting that medical workers do not include frostbite, burns, or insect bites in this list of injuries . Damage due to foreign bodies entering the pharynx, ear, nose, mouth and larynx is also excluded.
S06 Intracranial injury
Damage to the skull can be caused by a variety of reasons. Most often, intracranial injury is accompanied by contusion of the structures of the central nervous system or other serious pathology.
- Brain contusion. Such damage is most often characterized by focal macrostructural disruption of matter in the brain with varying degrees of severity. Diagnosis is carried out only in cases where the symptoms complement other signs of damage to the body. There are several degrees of injury:
- Easy . In this case, the person loses consciousness for several minutes, and also experiences nausea, dizziness and vomiting. All vital functions are not impaired. Fractures of the skull bones and hemorrhage are quite possible in the future.
- Average . A person loses consciousness for several tens of minutes or even hours. Headache and repeated vomiting appear. There are frequent manifestations of mental disorders, including agitation, decreased ability to speak and think normally. Blood pressure increases significantly, shortness of breath appears. There are frequent cases of partial amnesia in a person with a moderate degree of brain contusion.
- Heavy . The patient may lose consciousness for several hours or even days. Respiratory and vascular-motor system disorders appear. Symptoms are focal, mild, but slowly progressive. Brain hemorrhage appears, as well as bone fractures.
- Traumatic brain injury . Mechanical energy damage to the skull and brain. This concept includes not only the picture that develops in the initial hours after damage, but also the physiological and clinical manifestations inherent in the healing period.
ICD-10 codes for concussions, intracranial injuries and other head injuries:
- S06.0 Concussion . Functional damage to the brain, which is completely reversible. The person suffers a brief loss of consciousness. At subsequent levels of disease development, more pronounced changes appear.
- S06.1 Traumatic edema . Damage in which small bumps and abrasions appear on the head. This may indicate the presence of a cerebral hemorrhage. The symptoms are quite pronounced and are accompanied by vomiting and headache. There is a feeling of drowsiness and fatigue.
- S06.2 Diffuse brain injury . The most common type of traumatic brain injury, often caused by a road traffic accident.
Diffuse damage almost always begins with a fairly prolonged coma. One can immediately assume the development of such a disorder, especially if the stem functions are affected. - S06.3 Focal injury . Traumatic brain injury with focal damage to certain brain tissues. This disorder is characterized by the presence of a main focus of death of nerve tissue.
- S06.4 Epidural hemorrhage . A blood clot may form between the hard shell of the skull and the bones. This is precisely the consequence of violations that lead to all sorts of consequences. Bleeding in the human brain most often begins as a result of accidents or severe blows to the head.
- S06.5 Traumatic subdural hemorrhage . This type of hematoma is often associated with cranial symptoms. In this case, the blood thickens between the hard and arachnoid membranes of the brain, due to rupture of the veins. In a person, intracranial pressure increases and the substance of the brain is damaged.
- S06.6 Traumatic subarachnoid hemorrhage . With this type of hematoma, blood thickening occurs between the arachnoid and soft membranes. Occurs as a result of a ruptured artery or after a traumatic brain injury.
- S06.7 Intracranial disorder with prolonged coma . A person may become comatose as a result of injury or severe blow. In this case, an intracranial hematoma develops, which provokes a prolonged coma. Doctors initially eliminate the damage itself, after which they return the person to a normal state.
S00—S09 Head injuries
S00 Superficial head injury
- S00.0
Superficial injury to the scalp - S00.1
Contusion of the eyelid and periorbital area - S00.2
Other superficial injuries of the eyelid and periorbital region - S00.3
Superficial trauma to the nose - S00.4
Superficial ear injury - S00.5
Superficial injury to lip and oral cavity - S00.7
Multiple superficial head injuries - S00.8
Superficial injury to other parts of the head - S00.9
Superficial head injury, unspecified location
S01 Open head wound
- S01.0
Open wound of the scalp - S01.1
Open wound of the eyelid and periorbital region - S01.2
Open wound of the nose - S01.3
Open ear wound - S01.4
Open wound of the cheek and temporomandibular region - S01.5
Open wound of lip and oral cavity - S01.7
Multiple open wounds of the head - S01.8
Open wound of other areas of the head - S01.9
Open head wound, unspecified
S02 Fracture of the skull and facial bones
- S02.00
Closed calvarial fracture - S02.01
Open calvarial fracture - S02.10
Fracture of the base of the skull, closed - S02.11
Open fracture of the base of the skull - S02.20
Closed fracture of the nasal bones - S02.21
Open fracture of the nasal bones - S02.30
Fracture of the floor of the orbit, closed - S02.31
Open orbital floor fracture - S02.40
Fracture of the zygomatic bone and upper jaw, closed - S02.41
Open fracture of the zygomatic bone and upper jaw - S02.50
Closed tooth fracture - S02.51
Open tooth fracture - S02.60
Fracture of the lower jaw, closed - S02.61
Open fracture of the lower jaw - S02.70
Multiple fractures of the skull and facial bones, closed - S02.71
Multiple open fractures of the skull and facial bones - S02.80
Fractures of other facial bones and skull bones, closed - S02.81
Open fractures of other facial bones and skull bones - S02.90
Fracture of unspecified part of the skull and facial bones, closed - S02.91
Open fracture of unspecified part of the skull and facial bones
S03 Dislocation, sprain and strain of joints and ligaments of the head
- S03.0
Jaw dislocation - S03.1
Dislocation of the cartilaginous nasal septum - S03.2
Tooth dislocation - S03.3
Dislocation of other and unspecified areas of the head - S03.4
Sprain and strain of the jaw ligament joint - S03.5
Sprain and strain of joints and ligaments of other and unspecified parts of the head
S04 Cranial nerve injury
- S04.0
Injury to the optic nerve and visual pathways - S04.1
Oculomotor nerve injury - S04.2
Trochlear nerve injury - S04.3
Trigeminal nerve injury - S04.4
Abducens nerve injury - S04.5
Facial nerve injury - S04.6
Injury to the auditory nerve - S04.7
Accessory nerve injury - S04.8
Injury to other cranial nerves - S04.9
Cranial nerve injury, unspecified
S05 Injury to the eye and orbit
- S05.0
Conjunctival trauma and corneal abrasion without mention of foreign body - S05.1
Contusion of the eyeball and orbital tissues - S05.2
Laceration of the eye with prolapse or loss of intraocular tissue - S05.3
Laceration of the eye without prolapse or loss of intraocular tissue - S05.4
Penetrating wound of the orbit with or without the presence of a foreign body - S05.5
Penetrating wound of the eyeball with a foreign body - S05.6
Penetrating wound of the eyeball without a foreign body - S05.7
Eyeball avulsion - S05.8
Other injuries of the eye and orbit - S05.9
Injury to unspecified part of eye and orbit
S06 Intracranial injury
- S06.00
Concussion without open intracranial wound - S06.01
Concussion with open intracranial wound - S06.10
Traumatic cerebral edema without open intracranial wound - S06.11
Traumatic cerebral edema due to an open intracranial wound - S06.20
Diffuse brain injury without open intracranial wound - S06.21
Diffuse brain injury with open intracranial wound - S06.30
Focal brain injury without open intracranial wound - S06.31
Focal brain injury with open intracranial wound - S06.40
Epidural hemorrhage without open intracranial wound - S06.41
Epidural hemorrhage with open intracranial wound - S06.50
Traumatic subdural hemorrhage without open intracranial wound - S06.51
Traumatic subdural hemorrhage with open intracranial wound - S06.60
Traumatic subarachnoid hemorrhage without open intracranial wound - S06.61
Traumatic subarachnoid hemorrhage with open intracranial wound - S06.70
Intracranial injury with prolonged coma without open intracranial wound - S06.71
Intracranial injury with prolonged coma with open intracranial wound - S06.80
Other intracranial injuries without open intracranial wound - S06.81
Other intracranial injuries with open intracranial wound - S06.90
Intracranial injury, unspecified, without open intracranial wound - S06.91
Intracranial injury, unspecified with open intracranial wound
S07 Head crush
- S07.0
Facial crush - S07.1
Skull crushing - S07.8
Crushing of other parts of the head - S07.9
Crushing of unspecified part of head
S08 Traumatic amputation of part of the head
- S08.0
Scalp avulsion - S08.1
Traumatic ear amputation - S08.8
Traumatic amputation of other parts of the head - S08.9
Traumatic amputation of unspecified part of head
S09 Other and unspecified head injuries
- S09.0
Injury to blood vessels of the head, not elsewhere classified - S09.1
Injury to muscles and tendons of the head - S09.2
Traumatic rupture of the tympanic membrane - S09.7
Multiple head injuries - S09.8
Other specified head injuries - S09.9
Head injury, unspecified
Definition and features of coding
Closed TBI is considered to be damage to the brain without compromising the integrity of the surrounding tissues of the head and bone apparatus. These include: concussion and brain contusions, the formation of hematomas. Brain contusion in ICD 10 can be coded with several values, depending on the type of pathological process that has formed. Protocol E008, dedicated to closed brain injuries , contains a variety of codes under which the following types of injuries are encrypted:
- edema developing due to injury – S1;
- diffuse damage to brain tissue of varying severity - S2;
- traumatization with the presence of a specific focus – S3;
- epidural blood formation – S4;
- hemorrhage under the dura mater of the brain due to trauma – S5;
- post-traumatic accumulation of blood in the cavity between the pia mater and the arachnoid mater - S6;
- development of coma state – S06.7.
Each code contains complete information about the type and degree of development of post-traumatic pathology, which characterizes the further course of treatment and the presence of possible complications.
Causes and classification of the disease
The consequences of TBI according to ICD-10 are coded T90.5. Traumatic brain injury occurs when the soft tissues of the skull and brain are damaged. Most often the cause is:
- hitting the head;
- road traffic accidents;
- sports injuries.
All traumatic brain injuries are divided into 2 groups:
- open (penetrating and non-penetrating);
- closed.
If an injury occurs and it turns out that the integrity of the soft tissues of the head is broken, then this is a group of open injuries. If the bones of the skull are damaged, but the dura mater remains intact, then the injuries are classified as non-penetrating. They are called penetrating if the bones are damaged and the hard shell is also damaged. The closed form is characterized by the fact that the soft tissues are not affected, without an aponeurosis, and the skull bones are broken.
If we take into account the pathophysiology of TBI, then there are damages:
- Primary. In this case, blood vessels, skull bones, brain tissue, as well as the membrane are injured, and the cerebrospinal fluid system is also affected.
- Secondary. Not directly related to brain damage. Their development occurs as a secondary ischemic change in brain tissue.
There are injuries that cause complications, the most common among them:
- edema;
- stroke;
- hematoma.
The degree of severity must be taken into account:
- Easy. Consciousness is clear, there is no pain, there is no particular threat to health.
- Average. Consciousness can be clear, but it is also possible that the person feels a little stunned. Pronounced focal signs.
- Heavy. Stupor and severe stupor occur. Vital functions are disturbed, focal signs are present.
- Particularly heavy. The patient falls into a coma, either short-lived or deep. Vital functions are severely impaired, as are the cardiovascular and respiratory systems. Focal symptoms are present. Consciousness is absent from a couple of hours to many days. The movements of the eyeballs are blurred, and the reaction of the pupils to bright stimuli is depressed.
