head injury
TRANSCRIPT
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HEAD INJURIES – NEURO CRITICARE
By Dr. G. RAJARAMAN
HOD. NEURO SURGERYIGGGH & PGI, PONDICHERRY
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Traumatic Brain Injury
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INCIDENCE & PREVALENCEINCIDENCE & PREVALENCE In India 1990 4790 (000) 2000 49500 2007 53000 Vehicle 75% - Two Wheeler 14% - Cars Every year 200,00,000 TBI One HI per 15 seconds One Death per 8 MINUTES About 4000 CRORES of Rupees are spent on HI
every year.
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Our Hospital Incidence In 2004 – 2009 No of trauma admissions Male - 22, 784 - (5500 / year) Female - 6, 842 - ( 1350 /
year) Deaths - 1, 832 - ( 370 / year) About 20 inpatients per day At least one death per day
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COMMON SCENES IN OUR COMMON SCENES IN OUR ROADSROADS
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COMMON SCENES IN OUR COMMON SCENES IN OUR ROADSROADS
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FREQUENCY OF VARIOUS INJURIESFREQUENCY OF VARIOUS INJURIES(%) (%) IN MOTOR VEHICLE ACCIDENTSIN MOTOR VEHICLE ACCIDENTS
ExtremitiesExtremities 3434
Head and NeckHead and Neck 3232
ChestChest 2525
AbdomenAbdomen 1515
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CLASSIFICATION HI
1.Primary Injury2.Secondary InjuryPrimary HI
Impact InjurySkull FracturesFocal Brain InjuriesDiffuse Brain Injury
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SECONDARY BRAIN INJURY
Due to increased ICP – Heamatomas, Edema , Hypoxia, Hypotension, Ischemia and electrolytes abnormalities
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PRIMARY BRAIN INJURY TO BE AVOIDED
SECONDARY BRAIN INJURY MUST BE PREVENTED
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Brain Contusion
A brain contusion is defined by cell death accompanied by hemorrhage (leakage of blood)
The soft brain tissue is vulnerable to contusion in head trauma
The contusion often occurs at a site distant from the point of impact
Gross brain image from http://neuropathology.neoucom.edu/chapter4/chapter4bContusions_dai_sbs.html#contusion
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Epidural Hematomas
Slides from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com
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Sudural Hematomas
Slide from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com
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Diffuse Brain Swelling
Observe swelling (darker tissue) on brain CT scan of a 7-month-old victim of child abuse. What other injuries are present?
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Brain Swelling
Observe diffuse swelling (yellow tissue) and expansion of brain tissue into ventricles
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Swelling of the Brain
Brain surface image from www-medlib.med.utah.edu
Observe widening and flattening of gyri on brain surface
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Diffuse Axonal Injury
Occurs in up to 1/2 of traumatic brain injuries1
Is a diffuse form of injury, meaning that damage occurs over a more widespread area than in focal brain injury
Involves the shearing of axons in the white matter tracts
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Diffuse Axonal Injury
Is one of the major causes of unconsciousness and persistent vegetative state after head trauma.
Over 90% of patients with severe DAI never regaining consciousness (those that do wake up often remain significantly impaired)
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Diffuse Axonal Injury
A microscopic view of axonal degeneration
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Pathology of brain injury is differernt!
The volume of the intracranial vault =
Intracranial Contents: 80% brain tissue 10% blood 10% cerebrospinal fluid
An increase in the volume of any of these intracranial contents causes increased intracranial pressure
1. The brain can swell (edema)
2. Excess blood can accumulate due to hemorrhage
3. Cerebrospinal fluid can accumulate due to blockage of outflow
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The intracranial vault is a fixed volume --> Bone does not expand!
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BRAIN HERNIATIONS
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Pre-arrival
Resource identification and allocation
1o Survey 2o Survey
Basic Studies Specialty Studies
Reevaluation
Resuscitation
1o Therapy Definitive Therapy
Trauma:Initial Management Priorities Components of Management
1 Hour
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• Establish leadership - Involved leader- Remote leader
Anesthesiologist
CRNA1o Nurse
Tray
Line person
Chest tube person
Bystander
Bystander
Tray
CPR person
Bystander
Tray
Tray
Team Leader
Examining person2o Nurse
BystanderTray
Line person
Chest tube person
Bystander
Tray
Coffee maker
Trauma:Initial Management Priorities
• Organize team - Number / type of personnel
- Assess competency levels
- Assign tasks
Pre-arrival
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• Multiple medical teams and specialties
• Isolation and Precautions
• Machines
• Confined Space
• Access to ICU
• “Waiting Room Dynamics”
The ICU Culture
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• Personnel - Primary team- Specialty teams
• Facilities - Admitting area - 1o & 2o treatment areas
• Materials - “tubes”, “lines”, “trays”- Familiarity w. equipment
Assess:
Trauma:Initial Management Priorities
1 hour
Pre-arrival 1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
Pre-arrival
Pre-arrival
• Can the Institution handle this patient?
• … at this time?
• Are there alternative facilities nearby?
Assess:
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1o Survey
Resuscitation
2o Survey
Basic Studies Specialty Studies
Reevaluation
1o Therapy Definitive Therapy
1 hour
Pre-arrival
Airway:- assess- establish- maintain
Breathing:- assess- support
Circulation:- assess- access- stop hemorrhage- resuscitate
Trauma:Initial Management Priorities
Assess: • Immediate risk for loosing limb or life?
• Potential for (rapid) deterioration?
Primary Survey
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Difficult Airway Management
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WHAT IS THIS ?!
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TO KEEP IT OPEN- OPA
BenefitsBenefits and and
LimitatioLimitationsns
IndicatioIndications and ns and
ContrainContraindicationdication
ss
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CERVICAL SPINE FRACTURE
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AWESOME Tube Dude!Now what?
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Trauma patients usually do not die from lack of Hb but from hypovolaemia.
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Parameters Class I Class II Class III Class IV
Blood loss%ml
0 - 15750
15 - 30750-1500
30 - 401500-2000
>40>2000
Blood pressure Normal Normal Decreased Decreased
Pulse rate <100 >100>120
Thready
>140
Very thready
Capillary refill
Normal(<2 sec)
Slow >2 sec
>2 sec Undetectable
Respiratory rate
14 - 20 20 - 30 30 - 40 >35
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HEAD INJURY - MANAGEMENTGolden Hour: It is the FIRST 60 mts. Which decides the life or death4 Hour Rule4hrs – 30%4-24 hrs – 70 - 90%After24 hrs – 90 - 100% or PVS
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Head Trauma Usually signifies craniocerebral
trauma Includes alteration in consciousness High potential for poor outcome
Death at injury Death within 2 hours after injury Death 3 weeks after injury
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TIME
Time was gold Time was moneyTime is life
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E.R. MANAGEMENTCONTINUE THE BRAIN RESUSCITATION
INITIATED IN THE FIELD & TRANSPORT.
IMAGING FOR CEREBRAL AND SPINAL INJURIES.
EMERGENCY ROOM TREATMENT BEGINS WITH THE PATIENT ARRIVAL AND ENDS WITH TRANSFER TO THE OT (OR) NICCU.
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E.R. MANAGEMENT
A AIRWAYB BREATHINGC CIRCULATIOND DRUGSE EXAMINATIONF FLUIDS
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AIRWAY
POSITIONINGTHROAT CLEARINGMETALIC AIRWAYET TUBEEMERGENCY TRACHEOSTOMY
OUR AIM : Air should go into both the lungs EQUALLY AND ADEQUATELY
and to maintantain Spo2 > 90%
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BREATHING
HYPO VENTILATION – less than 10HYPERVENTILATION – more than 35ABNORMAL VENTILATIONS
- chyne stokes- Apneustic- Ataxic- Paradoxical
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CIRCULATION AIM is to maintain CPP > 70 ( at
least above 50 mm Hg )
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CPP CPP = MAP - ICP
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MAP MAP = DIASTOLIC + 1/3 PULSE
PRESSURE MAP = 2/3 diastolic + 1/3 systolic MAP = CO X PVR - CVP
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Autoregulation of Cerebral Blood Flow Blood vessels alter their diameter to ensure
a constant cerebral blood flow Lower limit for MAP is 50mm Hg. Below this, cerebral flow decreases and
there is risk of ischemia Upper limit is MAP of 150mmHg. Above this
the cerebral blood vessels are maximally constricted. Blood vessels cannot constrict more to control high pressure. Blood brain barrier is disrupted and cerebral edema and ICP results
MAP= DBP + 1/3 Pulse Pressure
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NORMAL ICP 8 – 12 mm Hg 10 – 15 cm of water
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Intracranial Pressure Monro-Kellie hypothesis (applies
only to children with a rigid skull and not neonates) Skull is an enclosed space with three
variables Brain tissue Blood Cerebrospinal fluid
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Volume (mL)
Pressure
(mmHg)
Intracranial Pressure Rises as Brain+Bood+CSF volume Increases
ICP > 20 mmHg
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CPP 100 – 20 = 80 90 – 20 = 70 90 – 50 = 40
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Intracranial Pressure -
ICP
CPP
This patient has dangerously high intracranial pressures, which increase the likelihood of morbidity and mortality
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Cerebral Perfusion Pressure (CPP)
Pressure needed to maintain blood flow to the brain
MAP-ICP=CPP Normal CPP is 60-100 CPP>100 is hyperperfusion and IICP CPP< 60 hypoperfusion CPP<30 incompatible with life
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ICP - MANAGEMENT Keep HOB elevated 30 degrees if BP is
normal If BP is low will need to put HOB flat Keep head in alignment to prevent
cutting off venous flow from the head Don’t elevate knees – this will increase
intrathoracic pressure Turn gently from side to side – if turning
raises ICP, pt will need to stay on back
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Drug Therapy Mannitol – Rapid short acting
diuretic that decreases ICP. Decreases total brain water content
Watch fluids and electrolytes closely (I and O and labs)
Don’t give in cases of renal failure or if serum osmolality increased
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Drug Therapy Loop diuretics – reduce blood
volume and tissue volume Corticosteroids – Decadron most
common steroid used. Watch for side effects. Should be on antacids or H2 receptor blockers to prevent ulcers.
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DRUGSANITIBIOTICSANALGESICANTIEPILEPTIC
EPSOLIN – Loading dose for patients having 2 or more fits - 15 mg / kg over ½ hour in
100 ml/NSProphylaxis and maintenance 5mg/kg/24
hrs in 2 to 3 divided dose.
ANTIEDEMALASIX (Freusemide) 20mg/IV/B.D. for adultMANNITOL 100ml IV TDS
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Acute Medical evaluation: CT Physical and neurological exam
Serial assessment
EXAMINATION
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Glasgow Coma Scale Best Eye Response. (4)
• No eye opening. • Eye opening to pain. • Eye opening to verbal command. • Eyes open spontaneously
Best Verbal Response. (5) • No verbal response • Incomprehensible sounds. • Inappropriate words. • Confused • Oriented
Best Motor Response. (6) • No motor response. • Extension to pain. • Flexion to pain. • Withdrawal from pain. • Localizing pain. • Obeys Commands.
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POINTS BEST EYE OPENING
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
6 - - OBEYS
5 - ORIENTED LOCALIZES PAIN
4 SPONTANEOUS
CONFUSED WITHDRAWS TO PAIN
3 TO SPEECH IN APPROPRIATE FLEXION RESPONSE
2 TO PAIN INCOMPREHENSIVE
EXTENSION RESPONSE
1 NONE NONE NONE
GLASGOW COMA SCALE (FOR AGE ≥ 4 YEARS)
E4 V5 M6 Minimum 3, Maximum 15
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POINTS BEST EYE OPENING
BEST VERBAL RESPONSE BEST MOTOR RESPONSE
6 - - OBEYS
5 - SMILES, FOLLOWS OBJECTS
LOCALIZES PAIN
4 SPONTANEOUS
CRYINGCONSOLABLE
INTERACTION
WITHDRAWS TO PAIN
3 TO SPEECH
INCONSISTENTLY CONSOLABLE
MOANING FLEXION
2 TO PAIN INCONSOLABLE
RESTLESS EXTENSION
1 NONE NONE NONE NONE
GLASGOW COMA SCALE (FOR AGE < 4 YEARS)
ANY CHANGE OF SCORE MORE THAN TWO IS IMPORANT
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Skull Fracture Locations Frontal Orbital fracture Temporal fracture Parietal fracture Posterior fossa fracture Basilar skull fracture
Occurs at base of the skull Watch for rhinorrhea and otorrhea Test fluid leaking from nose or ear for
glucose and watch for halo If the drainage is CSF then the fracture has
crossed the dura
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PUPILS
Bilateral Equal
> 1mm difference is significant
Change in size of pupils is indicative of III cranial nerve paralysis and coning on the side of DILATED PUPIL
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PULSE
TACHYCARDIA-PainHypotensionCardiac Causes
BRADYCARDIA- Increased in ICPHypoxiaCardiac Causes
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PUPILLARY DILATATION WITH BRADICARDIA
INCREASED INTRACRANIAL PRESSURE
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Battle’s sign
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FLUIDS
CRYSTALLOIDS AND COLLOIDSCRYSTALLOIDS
ISOTONIC – NS / RLHYPOTONIC – 5% DexHYPERTONIC - DNS
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FLUIDS
RL IS BETTER- Sodium - Na+- Potassium - K+- Calcium - Ca+- Bicarbonate as lactate
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SECONDARY SURVAY and Laboratory EEG Evoked potentials Lumbar puncture CT scan MRI scan Functional imaging Arteriography
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Evalution – CT Scan
EDH SDH
Thick - Hyperdense Thin
Localised Diffuse
Lens Sickle
Only Blood CSF Mic
Fracture Skull No
No Brain Injury Brain cont.
No SAH SAH
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What is this ?
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EXTRA DURAL HEMATOMA
AcuteSkull Fracture 65 – 90%< 2 > 60 years rare
85% Arterial Bleeding70% Vault – Epicentre @ PTERION
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ACUTE EXTRADURAL HAEMOTOMA
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Left fronto temporal EDH
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TREATMENT
Surgical Evacuation after craniotomyHaemostasisDural Hitch stichesDrainage
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SUB DURAL HEMATOMA
SDHVenous Brain LaceAcute, SA, Chronic.0-3 day 3 days to 3 week to
3 week 3 monthsPresentation: LOC – No LIMortality : 50-90%
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ACUTE SUBDURAL HAEMOTOMA
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Treatment: summary Protect the airway & oxygenate Ventilate to normocapnia Correct hypovolaemia and
hypotension Prevent herniation Surgery for hemorrhage, edema,
skull repair Medications for edema, infection,
agitation, coagulants, anticonvulsives, etc.
Rehabilitation
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The Value of Serial Observation
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Looking to the future…
Will new imaging technologies and TREATMENT lead to advances in patient care?
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Thanks for Your Attention
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Questions, / discussion
?
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THANK YOU
THANK YOU
VERYMUCH