suddural hematoma
TRANSCRIPT
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The curious case ofThe curious case of
Kevin, A cat and SDHKevin, A cat and SDH
Lisa Housel NARLisa Housel NAR
Jake Sareerak NARJake Sareerak NAR
Samuel Merritt UniversitSamuel Merritt Universit
Anatom and !hsiolo"Anatom and !hsiolo"
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#$ o Male %resentin" to %hsician &ith c'o HA ( )
&eek Hit head on %orch &hile searchin" for his cat
Headache *e"an at this time or shortl after HA continue to occur after ar"uments &ith &ife
Sm%toms+ ontinuous HA, all over head and e(tend to
%osterior neck muscles
Ti"ht neck muscles -ision and hearin" are .NL Denies nausea Hasn/t *een slee%in" &ell No relief &ith A!A! and i*u%rofen
ase Stud
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A01(2-S are .NL
Neck is su%%le and 3R1M
Tm%anic mem*rane, o%tic refle(es andretinae are intact
Stead "ait and DTR intact
Dia"nosed &ith muscle tension headache andtreated &ith sedative, muscle rela(ant and%ain medication
all MD if HA does not im%rove over the
&eekend
!hsical 4(amination
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7lood tests
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Referred to neurosur"eon
!erforms craniotom &ith evacuation of
hematoma !er sur"eon, &hen skull %ierced, *lood is
initiall released at a hi"h %ressure
HA minimal after sur"er6 "ood s%irits &ith
famil at *edside
Treatment
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%ir"ay &anagement:
Intubation: Indications for TBI patients:Intubation: Indications for TBI patients:
BRespiratory distress.Respiratory distress.
B&otor posturing'absence of response to pain.&otor posturing'absence of response to pain.
B(ypo)ia'hypercapnia.(ypo)ia'hypercapnia.
B*CS + ,.*CS + ,.
BSei-ures.Sei-ures.
BIncreased ICP.Increased ICP.
Beed for analgesics'sedati$es.eed for analgesics'sedati$es.
BSignificant associated injuries.Significant associated injuries.
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Secondary Brain Injury:
Pathophysiological response to primary neuronal injury
(ours to days after primary insult.
Progressi$e.
(ypo)ia'hypotension are main causes for /
nd
injury.(igh ICP.
(yperthermia.
Brain edema.
(emorrhage .
The primary focus of neurocritical care for TBI is the prevention,identification, and treatment of secondary brain injury.
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Subdural (ematomaTearing of bridging $eins:
Secondary to acceleration'deceleration.
Cresent shaped hematoma.
Hematoma much slower to develop (venous
origin) into a mass large enough to
produce sx
!amage due to impact:
(igher impact than that of E!(.
&ore brain injury and edema.
Treatment:
Symptomatic 0 1 cm thic at its biggest
pointSmaller subdurals may be obser$ed.
&ortality:
Range is 234536.
(igh mortality rate if:
!elay of surgery is 0 7 hrs.
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Cl ifi ti f H d (B i )
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Classification of Head (Brain)Injury
Minimal no loss of consciousness
or amnesia
GCS 15
Mild amnesia or brief (< 5 min)
LC! or im"airedalertness! memory
GCS 1#$15
%ost$concussi&e syndrome
Moderate LC ' 5 min! or focal
neuroloic deficit
GCS $1*
Se&ere
GCS < +
Clas"o& oma Scale7est Motor Res%onse+
1*es# Localies %ain
$ 3le(ion &ithdra&al
9 3le(ion a*normal
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The %eak incidence of SDH is in the #thand Eth
decades of life &hen a lar"er SD s%ace is
availa*le as a result of *rain atro%hThe enlar"ed s%ace accounts for the
%resentin" com%laint of focal sm%tomsrather than those associated &ith increased
5! Sm%toms ma mimic other health %ro*lems+
somnolence, confusion, lethar", andmemor lossF
SDH in 4lderl
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urrent headache is continuous
ommon sm%tom due to the mass effect ofhematoma causin" increase 5! and cere*ral
edema Headache is all over his head, and e(tends into his
%osterior neck muscles, &hich are ti"ht SDH &as *ilateral in ori"in, therefore, no
lateraliation occurred Stiffness of the neck and neck %ain could
additionall *e %resent &hen *lood has *eene(travasated into the su*@arachnoid s%ace
-ision and hearin" are normal and he has no nausea -isual and hearin" deficits &ould *e noted &ith an
5H SDH is located *et&een the dura and arachnoid
s%ace &hich causes %ressure6 venous in natureand usuall slo& *leedF
Si"nificance of
Sm%toms
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A!A! and 5*u%rofen did not relieve headache .HIII
HA related to *lood in su*dural s%ace increasin" 5!
Skull is ri"id, inelastic container that houses the
*rain, *lood volume and S3 Since inelastic container, onl small increases involume &ithin the com%artment can *etolerated *efore %ressure increasesdramaticall
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.hat is the si"nificance of each of the follo&in"
findin"s+ Kevin &as alert 0 oriented, and his vitalsi"ns &ere normal6 his neck &as su%%le and hadnormal ran"e of motion6 his skull &as normal on
%al%ation6 there &ere no si"ns of a*normal cranialnerve function6 his tm%anic mem*ranes &erenormal, as &ere his o%tic refle(es and retinae6 his"ait and dee% tendon refle(es &ere also normalI.hat %ossi*le %ro*lems &ere ruled out in thecourse of this e(aminationI
His sm%toms did not correlate &ith neurolo"icaldeficits that &ould result from a dramatic increasein 5! or herniation
His sm%tom reflect the a*ilit for the intracranialcom%artment to com%ensate for the e(tra *lood *decreasin" S3 %roduction to attem%t to maintainhomeostasis in relation to %ressure
Results of !hsical4(am
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7lood collected in the su*dural s%ace dra&s
&ater due to osmosis
3urther com%ressin" *rain tissueausin" ne& *leeds * tearin" other *lood
vessels
!atho%hsiolo"
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5ncreased thro**in" %ain
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.hIIIIII
H17 )$ to 9$ de"ree 5!
H17 9$ de"ree !!H17 flat 5! 8 More headache and %ain
!ositionin"@@H17 elevated &ith head midlineto avoid im%edin" venous return
5ncreased thro**in" %ain&hen lin" do&nI
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De%ends on the sie of the hematoma and the
de"ree of an associated %arenchmal *rain
inGur headache, nausea, confusion, %ersonalit chan"e,
decreased level of consciousness, s%eechdifficulties, other chan"e in mental status,
im%aired vision or dou*le vision, and &eaknessA dilated or nonreactive %u%il i%silateral to the
hematoma
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7ilateral fi(ed and dilated %u%ils are secondar toinadeuate cere*ral %erfusion
ere*ral h%o(ia and severe increased 5!
!u%ils that are fi(ed and dilated
5rreversi*le inGur
A unilateral fi(ed
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A findin" of si"nificant asmmetr durin" the
motor e(amination ma *e indicative of a
hemis%heric inGur and raises the %ossi*ilitof a mass lesionF
Mid*rain controls ocular motion
!ons coordination of ee and facialmovement
Hearin" and *alance
7alance and Cait
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Signs of Cerebral (erniation
8nconscious'unresponsi$e Patient8nconscious'unresponsi$e Patient
%symmetric pupils.%symmetric pupils.
!ilated or fi)ed pupil9s: unilaterally or bilaterally.!ilated or fi)ed pupil9s: unilaterally or bilaterally.
8nresponsi$e to painful stimuli.8nresponsi$e to painful stimuli.
Patient displays posturing.Patient displays posturing.
;irst abnormal fle)ion:;irst abnormal fle)ion: decorticatedecorticate..
Then abnormal e)tension:Then abnormal e)tension: deceberatedeceberate..
Cushing
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.hat does this indicatesI
Hi"h 5!
Hi"h 1%enin"
!ressure
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