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Head Trauma Head Trauma Objectives

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					Head Trauma
               Objectives:
A- Review specific of anatomy and physiology
  as related to head injuries.
B- Identify the principles of general
  management of the unconscious
  traumatized patient and the delayed
  complications.
C- Outline the method of evaluating head
  injuries using a mininurological
  examination.
D- Explain the management techniques to be
  used in specific types of head injuries.
E- Demonstrate the ability to assess various
  types of head, maxillofacial and neck
  injuries using a head-trauma model.
F- Explain clinical signs and outline priorities
  for initial management of injuries identified
  in the assessment.
                  Head Trauma
•   Neurosurgical consult essential
•   Early transfer reduces morbidity and mortality
•   Cardiorespiratory
•   Level of consciousness
•   Pupillary reaction
•   Vital signs
•   Associated injuries
•   Skull film results
          Cranial Nerve Assessment
• Pupils occulomotor nerve ( IIIrd )
• Others- lower assessment priority

• Alteration of Consciousness is The
  Hallmark of Brain Injury
          Unconsciousness Injury
•   Bilateral cerebral cortices
•   Brain stem RAS
•   Increased ICP
•   Decreased CBF

• Increased ICP Results in:
• Decreased perfusion
• Altered level of consciousness
                         History
•   Determine cause and effect
•   Pre- and post injury status
•   Document communicate
•   Reassess
                       Vital signs
•    Identifies status neurologically and systemically.
•   Respiratory Assessment
•   Assess and correct deficiencies
•   Increased ICP - slower RR
•   Increased ICP – noisy tachypnea
•   Asses for other etiology
                   Blood Pressure
•   Increased ICP Increased BP & widened
    pulse pressure
•   Assess for other etiology
•   Treat shock vigorously
                        Pulse
•   Increased ICP bradycardia
•   Tachycardia grave sign
•   Assess for etiology
                      Temperature
• Temperature
• Weather extremes
• Control hyperthermia

                  Eye Opening Response
•   Spontaneous – already open with blinking
    (normal) : four (4) points
•   To speech – not necessarily to request eye opening
    : three (3) points
•   To pain – stimulus should not be to face : two (2)
    points
•   None – make note if eyes are swollen shut : one (1)
    point
                 Verbal Response
• Oriented - knows name, age, etc. : five (5) points
• Confused conversation - still answers questions:
  four (4) points
• Inappropriate words - speech is either
  exclamatory or random : three (3) points
• Incomprehensible sounds - do not confuse with
  partial respiratory obstruction : two (2) points
• None – make note if intubation prevents speech:
  one (1) point
               Best Motor Response
•   Obeys - moves limb to command and pain
    is not required: six (6) points
•   Localizes - changing the location of the
    pain stimulus causes the limb to follow: five
    (5) points
•   Withdraws - pulls away from painful
    stimulus: four (4) points
•   Abnormal flexion - three (3) points
•   Extensor response - two (2) points
•   No movement - one (1) point
            C-spine Assessment
•   High index for suspicion
•   Reflex assessment
•   Sensory assessment
•   X-rays
     Hints to Cervical Cord Injury
• Flaccid areflexia, especially with flaccid rectal
  sphincter
• Diaphragmatic breathing
• Ability to flex forearms but not extend them
• Facial grimaces in response to pain above the
  clavicle but not below
• Hypotension without other evidence of shock (ie,
  hypotensive with warm extremities)
• Priapism is an uncommon but characteristic sign
• Brain stem responses :Neurosurgeon to
  perform occulocephalic & occulovestibular
  cranial nerve test.
• Skull X-rays
• Do not delay primary assessment &
  management to obtain skull X-rays.
   Management Reassessment, O2 and
               Airway
                    Concussion
• No significant brain injury or localizing signs
• History : amnesiac of event
• Admit : individualize
                     Contusion
• Significant alterations in consciousness and
  localizing signs
• Countercoup injury
• Admit and observe 48 hours
           Intracranial Hemorrhage
•   Meningeal or brain
•   CT - precise or diagnose
•   Clinical findings similar
•   Acute epidural
•   Middle meningeal artery tear
•   Rapidly fatal
•   Hallmark : ipsilateral, dilated fixed pupil
•   Immediate surgery
•   Prognosis : good
                    Acute Subdural
•   Venous hemorrhage
•   life- threatening gradual onset
•   severe underlying brain injury
•   Prognosis : poor
                     Subarachnoid
•   Bloody CSF, meningeal irritation
•   Headache, photophobia
•   Nuchal rigidity, R/O C-spine injury
•   High index of suspicion
•   Admit
            Closed Brain Hemorrhages
•   Occur at any location
•   CT- precise diagnosis
•   Neurological deficits- region and size of
    hemorrhage
          Increased ICP Complications
•   Cerebral edema
•   Vasospasm
•   Loss of autoregulation( Neurosurgical
    consult )
Fluid Restriction Prevent Overhydration
                      Diuretics
•   Neurological consult
•   Mannitol 50 gms IV
•   Furosemide 40-80 mg IV
•   Urinary catheter
              Deliberate Hypocapnia
•   Maintain PCO2 at 26-28 torr
•   Intubation
•   Latrogenic paralysis
•   Monitor ABGs ( Neurosurgical consult )
                             Convulsions
• Intracranial hemorrhage
                               Treatment
•   Diazepam 10mg IV
•    Diphenylhydantoin 1 gm IV
•   Phenobarbital or anaesthesia
•   Restlessness
•   Identify etiology
•   Correct cause
                               Hyperthermia
•   Potential disastrous
•   Reversible neurologic findings
•   Vigorous intervention
                               Scalp Wounds
•   Blood loss
•   Inspection
•   Repair
           Surgical Management
•   Obtain necessary tests early
•   Emergent surgeries for hematomas
•   Transfer to neurosurgeon
•   Avoid delays
                   Summary
A- Obtain and maintain an open airway
B- Ventilate to avoid hypercarbia
C- Treat shock, if present and look for cause
D- Except for shock, restrict fluid intake to
  maintenance levels
E- Establish baseline parameters
F- Search for associated injuries
G- Obtain X-rays as needed, but only after the
  patient is stable
H- Consult a neurosurgeon and consider early
  transfer
• I- Should the patient's condition show a
  change for the worse, consider other
  diagnoses and forms of treatment.
• Consult with a neurosurgeon and consider
  transfer.
• J- Reassess continually to identify changes
  necessitates neurosurgical intervention.

				
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posted:3/19/2012
language:English
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