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Head Trauma

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					น.พ.ประวัติวงศ์ วงศ์ ศรีแก้ว
   หน่ วยศัลยกรรมประสาท
     ร.พ.สรรพสิ ทธิประสงค์
                               1
   Describe basic intracranial physiology.
   Evaluate the head / brain-injured patient.
   Perform necessary stabilization procedures.
   Determine appropriate disposition.
   To know that the key to minimising secondary
    injury to brain tissue




                                                   2
   Common problem
   High morbidity and mortality
   Secondary results
    • Worsen outcome
    • Often preventable
   Early neurosurgical consult and transfer


                                               3
   Age and history
   Vital signs
   GCS score and pupils
   Alcohol / drug(s) intake
   Associated injuries
   Brain CT

                               4
                     Adults                   Infants/children
Eye opening      4   Spontaneous              Spontaneous
                 3   To voice                 To voice
                 2   To pain                  To pain
                 1   None                     None

Verbal           5   Oriented                 Alert, normal vocalization
                 4   Confused                 Cries but consolable
                 3   Inappropriate words      Persistently irritable
                 2   Incomprehensible words   Restless, agitated, moaning
                 1   None                     None

Motor response   6   Obeys commands           Spontaneous, purposeful
                 5   Localizes pain           Localizes pain
                 4   Withdraws                Withdraws
                 3   Abnormal flexion         Abnormal flexion
                 2   Abnormal extension       Abnormal extension
                 1   none                     none
                                                                            5
   10 mm Hg    =    Normal
   > 20 mm Hg =     Abnormal
   > 40 mm Hg =     Severe
   Many pathologic processes affect
    outcome
   ICP   Brain function,  outcome

                                          6
        Venous        Art.    Brain          CSF
        Volume        Vol.




        Ven.   Art.
                       Brain      Mass         CSF
        Vol.   Vol.



75 mL    Arterial                                          75 mL
                      Brain           Mass           CSF
         Volume

                                                                   7
        60-                     Herniation
ICP 55-
(mm Hg) 50-
        45-
        40-
        35-
        30-
        25-
        20-
        15-                        Point of
        10-                     Decompensation
         5-   Compensation
               Volume of Mass
                                                 8
              MBP – ICP = CPP
   Normal     90      10      80
  Cushing’s
  Response    100     20       80

Hypotension   50      20       30

    /
CPP = Cerebral Blood Flow, CBF is the key
                                            9
   CBF maintained with mean BP of 50 to
    160 mm Hg
   Moderate or severe brain injury 
    autoregulation often impaired
   Brain more vulnerable to episodes of
    hypotension


                                           10
   50 mL / 100 g / min    Normal
   < 25 mL / 100 g /min    EEG activity
   < 5 mL / 100 g / min   Cell death




                                            11
            Blunt         High velocity
   By                     Low velocity
Mechanism
            Penetrating   GSW
                          Other
            Mild          GCS = 14-15
   By
 Severity   Moderate      GCS = 9-13

            Severe        GCS = 3 - 8     12
 By Morphology
• Scalp Injury
                           Linear vs stellate
                 Vault     Depressed / nondepressed
• Skull                    Open / closed
  Fractures

                 Basilar   With / without CSF leak
                           With / without cranial palsy
• Brain Injury
                                                          13
By Morphology
                    Epidural
   Focal Injury     Subdural
                    Intracerebral

   Diffuse Injury   Cerebral concussion
                    Diffuse axonal injury

                                            14
Type                    Treatment
 Scalp Abrasion         Control bleeding
 Scalp Contusion        Debridement & sutured
 Scalp Laceration       Remove all foreign body
 Scalp Avulsion Flap    Flap rotation
 Scalp Skin Loss        Skin graft




                                                    15
Pre-op   Post-op




                   16
17
 Linear Fracture Skull
 Fracture Base Of Skull
 Depressed Skull Fracture
 Penetrating Fracture e.g. Missile injury




                                             18
19
 Fracture anterior base of skull


 Fracture middle base of skull


 Fracture posterior base of skull




                                     20
Fracture anterior base of skull

               Periorbital ecchymosis (Raccoon
               Eyes)

               CSF rhinorrhea

               Massive Epistaxis , Aware Le Fort Fx

               Cranial nerve I , II damage

               Developed C-C Fistula

               Pneumocephalus

               Meningitis


                                                       21
Periorbital ecchymosis   Pneumocephalus




                                          22
23
 CSF otorrhea
 Cranial nerve 7 palsy
 Hemotympanum
 Hearing Loss
 Retroauricura
  ecchymosis(Battle sign)
 Pneumocephalus
 Meningitis


                            24
25
 Ecchymosis at occipital area
 Developed posterior fossa EDH




                                  26
27
28
29
30
31
32
   Associated with skull fracture
 Classic: Middle meningeal artery tear
 Lenticular / biconvex due to dural
  adherence to skull
   Lucid interval



                                          33
   Can be rapidly fatal
 Early evacuation  prognosis
 Venous epidurals: Possible nonsurgical
  management
 Lucid Interval




                                           34
35
 Venous tear / brain laceration
 Covers entire cerebral surface

 Morbidity / mortality due to
  underlying brain injury
 Rapid surgical evacuation
  recommended, especially if > 5 mm
  shift of midline

                                      36
37
38
   Coup / contrecoup injuries
   Most common: Frontal / temporal
    lobes
   “Salt and pepper” appearance on CT
   CT changes usually progressive
   Most conscious patients: No operation

                                            39
40
41
   Transient loss of consciousness
   Normal head CT
   Nausea, vomiting
   Headache: If severe, repeat CT
   Symptoms may worsen before improvement
   Sequelae common

                                             42
   Prolonged deep coma (not due to mass
    lesion)
   Diffuse brain injury
   Motor posturing
   Frequent autonomic dysfunction



                                           43
   GCS Score = 14-15       X-rays as indicated
   History                 Alcohol / drug
                             screens as
   Exclude systemic         indicated
    injuries
                            Liberal use of head
   Neurologic exam          CT

     Observe or discharge based on findings

                                                   44
   GCS Score = 9-13        Admit and observe
   Initial evaluation       • Frequent
    same as for mild           neurologic exams
    injury                   • Repeat CT scan

   CT scan for all         Deterioration:
                             Manage as severe
                             head injury

                                                  45
   GCS Score = 3 – 8
   Evaluate / resuscitate
   Intubate for airway protection
   Focused neurologic exam
   Frequent reevaluation
   Identify associated injuries
   Care of C-spine injury

                                     46
Airway / Breathing
   Airway protection
   Supplemental oxygen
   Assisted ventilation
   Modest hyperventilation if necessary
    (PaCO2 at 25 - 35 mm Hg)
   Frequent reevaluation / ABGs

                                           47
Circulation
   Hypotension not due to brain injury
   Hypotension causes secondary brain
    injury
    • Correct hypotension quickly
    • Do not treat BP , maintain CPP


                                          48
Disability
   GCS
    • Eye opening
    • Best motor response
    • Verbal response
   Pupillary size, equality, reaction to light
   Symmetry of motor strength

                                                  49
Disability
   Minineurologic exam
    • On patient arrival
    • After resuscitation
    • Frequently
 Document changes
 Consult neurosurgeon early


                               50
Pupillary Finding              Cause
                       IIIrd nerve compression
                        bilaterally
                       Inadequate CNS perfusion


                       IIIrd nerve compression,
                        tentorial herniation
                       Optic nerve injury

                                                   51
Pupillary Finding           Cause
                       Drugs
                       Pontine lesion




                       Injured sympathetic
                        pathway

                                              52
Herniation
   Deteriorating (GCS score)
   Pupillary asymmetry
   Motor asymmetry
   Cardiopulmonary arrest
   Cushing’s response

                                53
54
All patients with suspicion
     of brain injury




                              55
 GCS < 13 (moderate-severe HI)
 Signs increase ICP
 Focal Neurodeficit (include seizure )
 Fracture Skull
 GCS drop
 Pre-op evaluation for multiple injuries
 Request




                                            56
   Intravenous fluids
    • Euvolemia
    • Isotonic-Hypertonic Solution

   Hyperventilation, if necessary
    • Goal: PaCO2 at 30 - 35 mm Hg




                                     57
   Mannitol
    • Use with signs of tentorial herniation
    • Dose: 0.5 - 1.0 g / kg IV bolus
   Other
    • Anticonvulsants
    • Sedation
    • Paralytics

                                               58
Scalp Injuries
   Possible site of major blood loss
   Direct pressure to control bleeding
   Occasional temporary closure




                                          59
Intracranial Mass Lesion
   May be life-threatening if expanding
    rapidly
   Immediate neurosurgical consult
   Hyperventilation / Mannitol
   ? Emergency burr holes ?

                                           60
61
   Maintain mean BP > 90 mm Hg
   Maintain PaCO2 between 25 - 35 mm Hg
   Use isotonic-hypertonic solution for
    euvolemia
   Frequent neurologic exams
   Liberal use of CT scans
   Early neurosurgical consult


                                           62
   Allow patient to become hypotensive
   Over-aggressively hyperventilate
   Use hypotonic IV fluids
   Use long-acting paralytics
   Paralyze before performing complete exam
   Depend on clinical exam alone

                                               63
 GCS < 13  CT brain-intracranial lesion
 Severe HI
 GCS drop
 Can not closely observation
 Impending Brain Herniation
 Request




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posted:8/25/2011
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