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surgery.Head injury.(dr.ari)
 

surgery.Head injury.(dr.ari)

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    surgery.Head injury.(dr.ari) surgery.Head injury.(dr.ari) Presentation Transcript

    • Head injuries
    • • A head injury is any trauma that leads to injury of the scalp, skull, or brain. These injuries can range from a minor bump on the skull to a devastating brain injury.
    • • Head injury can be classified as either closed or penetrating.• In a closed head injury, the head sustains a blunt force by striking against an object• In a penetrating head injury, an object breaks through the skull and enters the brain. (This object is usually moving at a high speed like a windshield or another part of a motor vehicle.)
    • • Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someones life.• In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.
    • Pathophysiology• Direct trauma.• Cerebral contusion.• Intracerebral shearing.• Cerebral edema.• I.C.H• Hydrocephalus
    • Traumatic Head Injury
    • Cerebral Edema• Cellular response to injury – Primary injury – Secondary injury • Hypoxic-ischemic injury – Injured neurons have increased metabolic needs – Concurrent hypotension and hypoxemia – Inflammatory response
    • The main factors which determine the severity of cerebral injury are:• Distortion of the brain.• Mobility of brain in relation to skull and meninges.• Configuration of interior of skull.• Deceleration and acceleration.• The pre-existing state of brain (elderly).
    • Brain injury:– Concussion.
    • ContusionLaceration
    • The Secondary pathology:• Intracranial : – Brain swelling. – Necrosis. Ischemia. – Hematoma. – Vascular changes. – Coning. – Coup & Counter-coup.
    • • Extracranial : – Resp. failure, increase CO2. – Systemic B/P – Fluid, isotonic. – Temperature
    • • For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours.• The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness
    • • If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.
    • • Signs of deterioration: – Becomes unusually drowsy – Develops a severe headache or stiff neck – Vomits more than once – Loses consciousness (even if brief) – Behaves abnormally
    • Skull fractures• Simple fracture.• Comminuted linear fracture of the vault.• Skull base linear fracture.• Depressed fracture. by: -falling objects. -Assault with a heavy blunt tool. -Missile injury. -R.T.A
    • • Compound depressed fracture: – Antibiotics. – Anti tetanus prophylaxis. – Surgery. Urgent.• Closed depressed fracture
    • Closed depressed fracture Indication of surgery:• Dural tear• Brain compression... (Dural venous sinuses.)• Compound.• Cosmetic.
    • Missile injuries:• Scalp injury.• Depressed skull fracture.• I.C.H.• Brain injury.
    • Management of Traumatic Head Injury• Maximize oxygenation and ventilation• Support circulation / maximize cerebral perfusion pressure CPP=MSP-ICP• Decrease intracranial pressure• Decrease cerebral metabolic rate
    • Monitoring• Serial neurologic examinations• Circulation / Respiration• Intracranial Pressure• Radiologic Studies• Laboratory Studies
    • Circulatory Support:Maintain Cerebral Perfusion Pressure 6 5Number of 4 GoodHypotensive ModerateEpisodes 3 Severe 2 Vegetative 1 Dead 0 Outcome Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)
    • Lowering ICP Brain Blood CSF Mass• Evacuate hematoma Bone• Drain CSF – Intraventricular catheters use is limited by degree of edema and ventricular effacement• Craniotomy – Permanence, risk of infection, questionable benefit
    • • Reduce edema• Promote venous return• Reduce cerebral metabolic rate• Reduce activity associated with elevated ICP
    • Management on head injuries• Minor head injury
    • Indications for admission to hospital:• Loss of consciousness.• Persistent drowsiness.• Focal neurological deficit.• Skull fracture.• Persisting nausea & vomiting• Elderly & infant.• W.
    • Management• Observation.• Bed elevated 20.• Mild fluid restriction.
    • Severe head injury• It depends on the patient’s neurological state and the intracranial pathology resulting from the trauma.• Clinical assessment and CT scan• Evacuation of any hematomas
    • • If there is no surgical lesion, or following the operation: – Observation and GCS chart – Decrease intracranial brain swelling • Airway management • Elevation of the head of the bed 20º • Fluid and electrolyte balance • Blood replacement with colloid or blood and not crystalloid • No steroids
    • – Management of conditions resulted from head injury • Severe hyponatraemia due to excessive fluid intake or inappropriate excessive secretion of ADH • Hypernatraemia due to inadequate fluid intake. • Diabetes insipidus
    • • Temperature control, pyrexia due to hypothalamic damage or traumatic SAH or infection or from CSF leak and meningitis
    • – Nutrition: • During the initial 2-3 days the fluid therapy will include 1.5-2 liters of 5% dextrose • After 3-4 days by nasogastric feeding
    • – Routine care of the unconscious patient, bowel, bladder and skin.– Intracranial monitoring in more severe cases.