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Neurologic TraumaNeurologic Trauma
Bryan E. Bledsoe, DO, FACEPBryan E. Bledsoe, DO, FACEP
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Neurologic TraumaNeurologic Trauma
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Neurologic TraumaNeurologic Trauma
Suppose you were anidiot. And suppose you
were a member ofCongress.
But I repeat myself.
Mark Twain
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Traumatic Brain n!ury "TB #Traumatic Brain n!ury "TB #
De$ined as a %low or !olt to t&e &ead or a'enetrating &eadin!ury t&at disru'tst&e $unction o$ t&e%rain.
De$ined as a %low or !olt to t&e &ead or a'enetrating &eadin!ury t&at disru'tst&e $unction o$ t&e%rain.
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(tatistics(tatistics
).* million 'eo'lesustain a TB eac& year
in t&e +nited (tates- , die,/0-, are &os'itali1ed,
).) million are treatedand released $rom t&eED.
).* million 'eo'lesustain a TB eac& year
in t&e +nited (tates- , die,/0-, are &os'itali1ed,
).) million are treatedand released $rom t&eED.
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(tatistics(tatistics
CausesFalls "/23#
M4Cs "/ 3#(truck %y5against e6ents ")73#Assaults "))3#
Blasts are t&e leading cause o$ TB $or acti6eduty military 'ersonnel in war 1ones.
CausesFalls "/23#
M4Cs "/ 3#(truck %y5against e6ents ")73#Assaults "))3#
Blasts are t&e leading cause o$ TB $or acti6eduty military 'ersonnel in war 1ones.
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(tatistics(tatisticsMales are a%out ).-times more likely tosustain a TB as a$emale.
Males are a%out ).-times more likely tosustain a TB as a$emale.
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(tatistics(tatistics
8ig&est risk $or TB9* years
)-9)7 years
A$rican Americans&a6e t&e &ig&estdeat& rate $rom TB .
8ig&est risk $or TB9* years
)-9)7 years
A$rican Americans&a6e t&e &ig&estdeat& rate $rom TB .
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(tatistics(tatistics
Estimated :; %illionlost $rom TB "medicalcosts and lost'roducti6ity#.uent ty'e o$ TB
Most common in(u%$rontal corte?Frontal lo%eTem'oral lo%e
Occi'ital "less common#O$ten associated wit& (A8.
Cere%ral contusionMost $re>uent ty'e o$ TB
Most common in(u%$rontal corte?Frontal lo%eTem'oral lo%e
Occi'ital "less common#O$ten associated wit& (A8.
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Trauma Ty'esTrauma Ty'es
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ContusionContusion
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Trauma Ty'esTrauma Ty'es
(u%arac&noid&emorr&age
Disru'tion o$su%arac&noid 6essels.)50 o$ all 'atients wit&moderate to se6ere TB
&a6e traumatic (A8.
(u%arac&noid&emorr&age
Disru'tion o$su%arac&noid 6essels.)50 o$ all 'atients wit&moderate to se6ere TB
&a6e traumatic (A8.
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Trauma Ty'esTrauma Ty'es
E'idural &ematomaCollection o$ %lood %etween t&e dura and t&eskull.Arterial %leed.
ncidence.-9). 3 o$ all &ead9in!ured 'atients.
H) 3 o$ &ead9in!ured 'atients w&o are comatose.Almost all associated wit& skull $racture.2 3 will 'rogress to uncal &erniation.
E'idural &ematomaCollection o$ %lood %etween t&e dura and t&eskull.Arterial %leed.
ncidence.-9). 3 o$ all &ead9in!ured 'atients.
H) 3 o$ &ead9in!ured 'atients w&o are comatose.Almost all associated wit& skull $racture.2 3 will 'rogress to uncal &erniation.
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E'idural 8ematomaE'idural 8ematoma
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E'idural 8ematomaE'idural 8ematoma
(igns and (ym'tomsClassis syndrome "H/ 3 o$ cases#
mmediate =OC.Patient awakens and &as a Llucid inter6al.=oses consciousness as &ematoma e?'ands.
Most commonly
Most 'atients eit&er ne6er lose consciousness orne6er regain consciousness.
(igns and (ym'tomsClassis syndrome "H/ 3 o$ cases#
mmediate =OC.Patient awakens and &as a Llucid inter6al.=oses consciousness as &ematoma e?'ands.
Most commonly
Most 'atients eit&er ne6er lose consciousness orne6er regain consciousness.
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Trauma Ty'esTrauma Ty'es
(u%dural &ematomaCollection o$ %lood%etween t&e dura andt&e (AM.4enous %leed.Associated wit&
sudden accelerationand5or deceleration.Tears %ridging 6eins.
(u%dural &ematomaCollection o$ %lood%etween t&e dura andt&e (AM.4enous %leed.Associated wit&
sudden accelerationand5or deceleration.Tears %ridging 6eins.
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(u%dural 8ematoma(u%dural 8ematoma
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(u%dural 8ematoma(u%dural 8ematoma
+sually more %rain 'arenc&ymal in!uryt&an e'idurals.
Classi$ied asAcute "H 0 days#(u%acute "09)* days#C&ronic "I )* days#
+sually more %rain 'arenc&ymal in!uryt&an e'idurals.
Classi$ied asAcute "H 0 days#(u%acute "09)* days#C&ronic "I )* days#
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Trauma Ty'esTrauma Ty'es
Di$$use A?onal n!ury "DA #nterru'tion o$ a?onal $i%ers in t&e w&ite
matter and %rain stem.(&earing $orces "usually deceleration# causein!ury.
Adults M4Cs
Ba%ies L(&aken %a%y syndromen!ury occurs immediately and is usually
irre6ersi%le.
Di$$use A?onal n!ury "DA #nterru'tion o$ a?onal $i%ers in t&e w&ite
matter and %rain stem.(&earing $orces "usually deceleration# causein!ury.
Adults M4Cs
Ba%ies L(&aken %a%y syndromen!ury occurs immediately and is usually
irre6ersi%le.
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Di$$use A?onal n!uryDi$$use A?onal n!ury
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Trauma Ty'esTrauma Ty'es
ntracere%ral8emorr&age
+sually caused %ys&earing $orces.(e6erity de'ends u'onlocation and si1e.
(econdary in!urycommon.
ntracere%ral8emorr&age
+sually caused %ys&earing $orces.(e6erity de'ends u'onlocation and si1e.
(econdary in!urycommon.
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Trauma Ty'esTrauma Ty'es
Pro%a%ly mortal.Pro%a%ly mortal.
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TB (igns and (ym'tomsTB (igns and (ym'toms
An?iety5ner6ousnessBe&a6ioral c&anges
Disin&i%itionm'ulsi6enessna''ro'riate laug&ter rrita%ility
Di'lo'iaDe'ressionTrou%le concentrating
An?iety5ner6ousnessBe&a6ioral c&anges
Disin&i%itionm'ulsi6enessna''ro'riate laug&ter rrita%ility
Di'lo'iaDe'ressionTrou%le concentrating
A'&asiaDys'&agiaDi11iness8eadac&e+ncoordination o$mo6ements
=ig&t&eadednessAta?iaAmnesia
A'&asiaDys'&agiaDi11iness8eadac&e+ncoordination o$mo6ements
=ig&t&eadednessAta?iaAmnesia
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TB (igns and (ym'tomsTB (igns and (ym'toms
Musclesti$$ness5s'asm(ei1ures(lee' disorders(lurred or sloweds'eec&
TinglingNum%nessPain
Musclesti$$ness5s'asm(ei1ures(lee' disorders(lurred or sloweds'eec&
TinglingNum%nessPain
4ertigo=ocali1ed weaknessNausea4omitingBody tem'eraturec&anges
ComaPosturingPu'illary a%normality
4ertigo=ocali1ed weaknessNausea4omitingBody tem'eraturec&anges
ComaPosturingPu'illary a%normality
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TB (igns and (ym'tomsTB (igns and (ym'toms
( N( AND ( MPTOM(
N TBA E E T EME=
4A AB=E
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Assessment5TreatmentAssessment5Treatment
Airway "wit& c9s'ine control#
Breat&ingCirculationDisa%ility
E?'osure
Airway "wit& c9s'ine control#
Breat&ingCirculationDisa%ility
E?'osure
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Assessment5TreatmentAssessment5Treatment
Pal'ate skull, $acial %ones and neckAssess rate, de't& and >uality o$
res'irations.Consider tac&y'nea at t&e $ollowing rates asign o$ deterioration
n$ant * %reat&s 'er minute
C&ild 0 %reat&s 'er minuteAdult / %reat&s 'er minute
Pal'ate skull, $acial %ones and neckAssess rate, de't& and >uality o$
res'irations.Consider tac&y'nea at t&e $ollowing rates asign o$ deterioration
n$ant * %reat&s 'er minute
C&ild 0 %reat&s 'er minuteAdult / %reat&s 'er minute
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Assessment5TreatmentAssessment5Treatment
Assess 'u'ils care$ullyPu'il si1e
(ymmetryeacti6ity to lig&t
Assess 'u'ils care$ullyPu'il si1e(ymmetry
eacti6ity to lig&t
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Assessment5TreatmentAssessment5Treatment
Pu'illary assessmentBilateral symmetry "asymmetric 'u'ils di$$ermore t&an ) mm#.
eacti6ity to lig&t "a $i?ed 'u'il s&ows H)mmc&ange in res'onse to %rig&t lig&t#.Dilation "greater t&an or e>ual to *mm
diameter in adults#
Pu'illary assessmentBilateral symmetry "asymmetric 'u'ils di$$er more t&an ) mm#.
eacti6ity to lig&t "a $i?ed 'u'il s&ows H)mmc&ange in res'onse to %rig&t lig&t#.Dilation "greater t&an or e>ual to *mm
diameter in adults#
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Assessment5TreatmentAssessment5Treatment
(ingle $i?ed and dilated 'u'il*-3 'oor outcome
Bilateral $i?ed and dilated 'u'ils2/3 'oor outcome
(ingle $i?ed and dilated 'u'il*-3 'oor outcome
Bilateral $i?ed and dilated 'u'ils2/3 'oor outcome
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Assessment5TreatmentAssessment5Treatment
Mid9'osition $i?ed anddilated 'u'il
(uggests %rain stem
&erniation.ndicati6e o$ mass on
same side.Treat &y'o?ia and
&y'otension, i$ 'resent.Treat increased CP 'er'ractice 'arameters.
Mid9'osition $i?ed anddilated 'u'il
(uggests %rain stem
&erniation.ndicati6e o$ mass on
same side.Treat &y'o?ia and
&y'otension, i$ 'resent.Treat increased CP 'er'ractice 'arameters.
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Assessment5TreatmentAssessment5Treatment
ndications o$ &erniation+nilateral or %ilateral dilated, nonreacti6e'u'ils.Asymmetric 'u'ils.Decere%rate 'osturing.No motor res'onse to 'ain$ul stimuli.
ndications o$ &erniation+nilateral or %ilateral dilated, nonreacti6e'u'ils.Asymmetric 'u'ils.Decere%rate 'osturing.No motor res'onse to 'ain$ul stimuli.
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Assessment5TreatmentAssessment5Treatment
Monitor ('O / and ETCO / .Maintain ('O / I 7 3
Maintain ETCO / %etween 0-90@ mm 8gnitiate 4 line wit& salineMaintain adult systolic BP I 7 mm 8g
Pediatric 6alues are lower.+tili1e lasgow Coma (cale
Monitor ('O / and ETCO / .Maintain ('O / I 7 3
Maintain ETCO / %etween 0-90@ mm 8gnitiate 4 line wit& salineMaintain adult systolic BP I 7 mm 8g
Pediatric 6alues are lower.+tili1e lasgow Coma (cale
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lasgow Coma (cale "Adult#lasgow Coma (cale "Adult#
Eye O'ening "E# 4er%al es'onse "4# Motor es'onse "M#O !"# $6
Or&!'(!) $5 Lo*al&+!# $5
S,o'(a'!o-# $4 Co'.-#!) $4 /&( )ra # $4
R!a*(&o' (o S,!!* $3 I'a,,ro,r&a(! /or)# $3 D!*or(&*a(! $3
R!a*(&o' (o a&' $2 I'*om,r! !'#& l!So-')# $2
D!*!r! ra(! $2
No R!#,o'#! $1 No R!#,o'#! $1 No R!#,o'#! $1
O AL E M
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lasgow Coma (cale " n$ant#lasgow Coma (cale " n$ant#
Eye O'ening "E# 4er%al es'onse "4# Motor es'onse "M#O !"# $6
Coo# Ba l!# $5 Lo*al&+!# $5
S,o'(a'!o-# $4 Irr&(a l! Cr" $4 /&( )ra # $4
R!a*(&o' (o S,!!* $3 Cr&!# (o a&' $3 D!*or(&*a(! $3
R!a*(&o' (o a&' $2 Ma'# r-'(# $2 D!*!r! ra(! $2
No R!#,o'#! $1 No R!#,o'#! $1 No R!#,o'#! $1
O AL E M
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Assessment5TreatmentAssessment5Treatment
Assess %loodglucose le6el.Assess %loodglucose le6el.
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Treat AirwayTreat Airway
Protect C9s'ine alignment, consider$acial trauma.
Airway su''ort 'er sco'e o$ 'ractice.ntu%ate se6ere TB 'atients.Correct &y'o?ia.
Protect C9s'ine alignment, consider$acial trauma.
Airway su''ort 'er sco'e o$ 'ractice.ntu%ate se6ere TB 'atients.Correct &y'o?ia.
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J&en to ntu%ateJ&en to ntu%ate
C( H 7 "se6ereTB #.
All 'atients wit&res'iratory $ailure o$a'nea.
C( H 7 "se6ereTB #.
All 'atients wit&res'iratory $ailure o$a'nea.
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Treat Breat&ingTreat Breat&ing
O?ygenation.Administer su''lemental o?ygen %y non9re%reat&er or B4M as a''ro'riate.
4entilation.Assess rate, de't&, >uality, to determine t&ee$$ecti6eness o$ res'irations.As necessary, assist 6entilations wit& B4Mand su''lemental O / .
O?ygenation.Administer su''lemental o?ygen %y non9re%reat&er or B4M as a''ro'riate.
4entilation.Assess rate, de't&, >uality, to determine t&ee$$ecti6eness o$ res'irations.
As necessary, assist 6entilations wit& B4Mand su''lemental O / .
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Treat Breat&ingTreat Breat&ing
Adult normal4entilation rate
) 9)/ 'er minute
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8y'er6entilation8y'er6entilation
8y'er6entilationa'id PaCO /
Cere%ral 6asoconstrictionDecreased CBF CP
But, &y'er6entilation can CBF to t&e'oint o$ isc&emia.Monitor ETCO / Q
8y'er6entilationa'id PaCO /
Cere%ral 6asoconstrictionDecreased CBF CP
But, &y'er6entilation can CBF to t&e'oint o$ isc&emia.Monitor ETCO / Q
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8y'er6entilation8y'er6entilation
Potential &arm in 'atients wit&oute6idence o$ %rain &erniation.
(&ort9term measure used in s'eci$ic TB'atients "&erniation# until de$initi6ediagnostic or t&era'eutic can %e'ro6ided.
Potential &arm in 'atients wit&oute6idence o$ %rain &erniation.
(&ort9term measure used in s'eci$ic TB'atients "&erniation# until de$initi6ediagnostic or t&era'eutic can %e'ro6ided.
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8y'er6entilation8y'er6entilation
atesAges 79Adult / %reat&s 'er minute
"ETCO / K 0- mm 8g#.
Ages )92 years 0 %reat&s 'er minute"ETCO / K 0/90- mm 8g#.
Ages H ) year * %reat&s 'er minute"ETCO / K 0/90- mm 8g#.
atesAges 79Adult / %reat&s 'er minute
"ETCO / K 0- mm 8g#.
Ages )92 years 0 %reat&s 'er minute"ETCO / K 0/90- mm 8g#.
Ages H ) year * %reat&s 'er minute"ETCO / K 0/90- mm 8g#.
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FluidsFluids
Fluids to maintain (BPI 7 mm 8g.Normal saline8y'ertonic saline
Fluids to maintain (BPI 7 mm 8g.Normal saline8y'ertonic saline
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Brain9Targeted T&era'iesBrain9Targeted T&era'ies
lucose $or &y'oglycemia(edati6es $or agitation
Analgesics $or 'ainParalytics $or ET intu%ationContro6ersial
Mannitol=idocaine8y'ertonic (aline
lucose $or &y'oglycemia(edati6es $or agitationAnalgesics $or 'ainParalytics $or ET intu%ationContro6ersial
Mannitol=idocaine8y'ertonic (aline
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DestinationsDestinations
Mild " C( )*9)-# Emergency De'artmentModerate " C( 79)0# Trauma Center
(e6ere " C( H 7# Trauma Center wit&se6ere TB management ca'a%ilities.
Mild " C( )*9)-# Emergency De'artmentModerate " C( 79)0# Trauma Center
(e6ere " C( H 7# Trauma Center wit&se6ere TB management ca'a%ilities.
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Take 8ome MessagesTake 8ome Messages
Clinical 'ractice s&ould %e e6idence9%ased.
Do early and re'eated neurologicalassessments.denti$y 'atients wit& se6ere TB " C( H
7#.
Clinical 'ractice s&ould %e e6idence9%ased.
Do early and re'eated neurologicalassessments.denti$y 'atients wit& se6ere TB " C( H
7#.
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Take 8ome MessagesTake 8ome Messages
A6oid &y'o?ia, kee' ('O / I 7 3.A6oid &y'otension, kee' (BP I 7 mm
8g.8y'er6entilate only $or clinical signs o$&erniation.
Triage and trans'ort TB to a''ro'riate$acilities %ased on se6erity.
A6oid &y'o?ia, kee' ('O / I 7 3.A6oid &y'otension, kee' (BP I 7 mm
8g.8y'er6entilate only $or clinical signs o$&erniation.
Triage and trans'ort TB to a''ro'riate$acilities %ased on se6erity.
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T&e FutureT&e Future
T&era'ies to 'rotect against secondaryin!ury
8y'ot&ermia.(edati6e9induced coma.Meta%olic t&era'ies.Antio?idant t&era'ies.
T&era'ies to 'rotect against secondaryin!ury
8y'ot&ermia.(edati6e9induced coma.Meta%olic t&era'ies.Antio?idant t&era'ies.