management of head trauma1 undergradua

8/8/2019 Management of Head Trauma1 Undergradua

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ManagementManagement

Of Head InjuryOf Head Injury



EpidemiologyEpidemiology-- Head injury is a major cause of disability, deathHead injury is a major cause of disability, death

& economic costs to our society& economic costs to our society

-- In USA:In USA: --75,000 Death per year 75,000 Death per year --375,000 hospitalized375,000 hospitalized--1,975,000 medically attended1,975,000 medically attended

-- 50% of all deaths related to trauma are due to50% of all deaths related to trauma are due tosevere head injurysevere head injury

-- Persons between 15Persons between 15--24 years old are at high24 years old are at high

risk, male predominantrisk, male predominant-- SocioSocio--economic and poor driving behaviors areeconomic and poor driving behaviors are

important negative factorsimportant negative factors



Classif ication Of Head InjuryClassif ication Of Head Injury

** Anatomical Anatomical::Scalp, Skull, Brain parenchyma,Scalp, Skull, Brain parenchyma,Ventricles, Vessels, nervesVentricles, Vessels, nerves

**Mechanism of injuryMechanism of injury::R.T. A., Fall, Assault, Gun shot, etc..R.T. A., Fall, Assault, Gun shot, etc..

**Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)



Glasgow Coma ScaleGlasgow Coma Scale**EyeEye--Opening ( E ):Opening ( E ):--Spontaneous 4Spontaneous 4

--To voice 3To voice 3

--To Pain 2To Pain 2

--No Response 1No Response 1

* * Best Motor Response (M)Best Motor Response (M)::--Obey commands 6Obey commands 6

--Localizes 5Localizes 5

--Withdraws( Flexion) 4Withdraws( Flexion) 4

--Abnormal Flexion Abnormal Flexion(decorticate rigidity) 3(decorticate rigidity) 3

--ExtensionExtension

(decerebrate rigidity) 2(decerebrate rigidity) 2

--No response 1No response 1

**Verbal Response ( V ):Verbal Response ( V ):--Oriented conversation 5Oriented conversation 5

--Confused, Disoriented 4Confused, Disoriented 4

--Inappropriate words 3Inappropriate words 3

--IncomprehensibleIncomprehensible--Sounds 2Sounds 2

--No response 1No response 1

**GCS SCOREGCS SCORE = E + M + V= E + M + V

**Fully conscious:Fully conscious: 15/1515/15



Classif icationClassif ication (According to GCS)(According to GCS)

MINORMINOR H.I. GCSH.I. GCS 1414--1515

MODERETEMODERETE H.I. GCSH.I. GCS 99--1313

SEVERESEVERE H.I. GCSH.I. GCS 33--88



Neuropathology of Head Injury Neuropathology of Head Injury

PRIMARY DAMAGEPRIMARY DAMAGE Laceration of the scalpLaceration of the scalp

Fracture of the skullFracture of the skull* * V ault:V ault: (linear, depressed , open)(linear, depressed , open)

* * Basilar:Basilar: (CSF leak, cranial nerve palsy)(CSF leak, cranial nerve palsy)

Intracranial lesionsIntracranial lesions**F ocal F ocal : Epidural, Subdural, Intracerebral: Epidural, Subdural, Intracerebral

hematoma, & brain contusionhematoma, & brain contusion

**DiffuseDiffuse: Concussion ,: Concussion , Diffuse Axonal InjuryDiffuse Axonal Injury



DIFFUSE AXONAL INJURY (DAI)DIFFUSE AXONAL INJURY (DAI)Definition:Definition:

Widespread axonal damage secondary toWidespread axonal damage secondary to

trauma which istrauma which is not a consequence of not a consequence of

herniation or perfusionherniation or perfusion failurefailure



Neuropathology of Head Injury Neuropathology of Head Injury

*SECONDARY DAMAGE*SECONDARY DAMAGE*Hypotension :*Hypotension : SBP < 90 mm HgSBP < 90 mm Hg

*HYPOXIA*HYPOXIA :: PO2 <60 mm HgPO2 <60 mm Hg

*Brain Edema*Brain Edema

*Brain Ischemia*Brain Ischemia

*Persistent Elevation OF ICP *Persistent Elevation OF ICP

*Infection*Infection

*Pyrexia*Pyrexia

*Seizure*Seizure

*Hydrocephalus*Hydrocephalus



M anagement of Head injury M anagement of Head injury

PREHOPITAL CAREPREHOPITAL CAREInIn--thethe--field:field:--Proper historyProper history

-- ABC ABC

--General examinationGeneral examination--GCS GCS

--Signs of ICP :Signs of ICP :

*Unilateral or bilateral papillary dilatation.*Unilateral or bilateral papillary dilatation.

* Asymmetrical papillary reaction to light.* Asymmetrical papillary reaction to light.*Decorticate or decerebrate posturing.*Decorticate or decerebrate posturing.

*Progressive deterioration in LOC.*Progressive deterioration in LOC.




PREHOPITAL CAREPREHOPITAL CARE- -Intubate patient with GCS 8 or below Intubate patient with GCS 8 or below

- -If there is signs of high I CP:If there is signs of high I CP:

*Controlled hyperventilation*Controlled hyperventilation

*sedation*sedation*mannitol*mannitol

- -TR ANSPO RT ATI ON TR ANSPO RT ATI ON

*Spinal stability: Spinal board, cervical*Spinal stability: Spinal board, cervicalcollar, sandbagscollar, sandbags




M ILD H.I M ILD H.I.. ( GCS 14( GCS 14--15)15)* Asymptomatic and neurologically normal:* Asymptomatic and neurologically normal:

--D/C from emergency room with aD/C from emergency room with a ³ warning ³ warning sheet´ sheet´ and OPD followand OPD follow--upup

*Symptomatic patient with history of LOC, Amnesia,*Symptomatic patient with history of LOC, Amnesia,neurological symptoms, Associated injuries:neurological symptoms, Associated injuries:

--CT scanCT scan

--Admit to the hospital for observation ~ 24 H Admit to the hospital for observation ~ 24 H--I/V fluids , mild analgesia , antiI/V fluids , mild analgesia , anti--emeticemetic




M ODERATE H.I.M ODERATE H.I. ( GCS 9( GCS 9--13 )13 )--CT scanCT scan

--Admit to the hospital Admit to the hospital

--With abnormal CT

scan , admit to ICUWith abnormal CT

scan , admit to ICU--With normal CT scan , admit to the floor for :With normal CT scan , admit to the floor for :

*Frequent neurological checks*Frequent neurological checks*Follow*Follow--up CT scan if condition deterioratesup CT scan if condition deteriorates

# 90 % of patient improve# 90 % of patient improve# 10 % of patient deteriorates, Need more hospital# 10 % of patient deteriorates, Need more hospital

stay and observationstay and observation




SE V ERE HEAD INJURY SE V ERE HEAD INJURY (GCS 3(GCS 3--8)8) ..

* * G uidelines of management :G uidelines of management :# Mech. Vent., plain x# Mech. Vent., plain x--ray (chest & spine), CT brainray (chest & spine), CT brain

# ICU care# ICU care

# Management of High ICP:# Management of High ICP: --ICP monitoring, CPPICP monitoring, CPP

--Head elevationHead elevation

--HyperventilationHyperventilation

--DiureticsDiuretics

--MannitolMannitol

--BarbituratesBarbiturates

# Anti# Anti--SeizureSeizure

# Nutrition# Nutrition




SURGICAL LESIONS SURGICAL LESIONS (15(15--20%)20%)

M ay NEED UR GEN T M ay NEED UR GEN T

I N

T E

RV EN

TI ON

I N

T E

RV EN

TI ON

e.g.,e

.g.,

--Depressed and open skull fractureDepressed and open skull fracture

--Epidural, Subdural, Intracerebral hematomasEpidural, Subdural, Intracerebral hematomas

--Penetrating head injuriesPenetrating head injuries--Large contusion with mass effectLarge contusion with mass effect



M anagement of Severe Head injury M anagement of Severe Head injury

OutcomeOutcome*Mortality: 40*Mortality: 40--45%45%

*Vegetative: 5%*Vegetative: 5%*Severely Disabled: 15%*Severely Disabled: 15%

*Moderately Disabled: 15%*Moderately Disabled: 15%

*Good Recovery: 20%*Good Recovery: 20%



CONCLU S I ON CONCLU S I ON

P R E V EN TI ON P R E V EN TI ON IS THE MOST EFFECTIVEIS THE MOST EFFECTIVE

MANAGEMENT FOR SEVEREMANAGEMENT FOR SEVEREHEAD INJURYHEAD INJURY

management of head trauma1 undergradua

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