Surgery 5th year, 2nd/part two, 3rd & 4th lectures (Dr. Ari Sami)


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The lecture started on Dec. 9th, 2010 and ended on Feb. 10th, 2011 by Dr. Ari Sami.

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Surgery 5th year, 2nd/part two, 3rd & 4th lectures (Dr. Ari Sami)

  1. 1. Head injuries
  2. 4. <ul><li>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. </li></ul>
  3. 5. <ul><li>Head injury can be classified as either closed or penetrating. </li></ul><ul><li>In a closed head injury , the head sustains a blunt force by striking against an object </li></ul><ul><li>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.) </li></ul>
  4. 6. <ul><li>Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life. </li></ul><ul><li>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. </li></ul>
  5. 7. Pathophysiology <ul><li>Direct trauma. </li></ul><ul><li>Cerebral contusion. </li></ul><ul><li>Intracerebral shearing. </li></ul><ul><li>Cerebral edema. </li></ul><ul><li>I.C.H </li></ul><ul><li>Hydrocephalus </li></ul>
  6. 8. Traumatic Head Injury
  7. 9. Cerebral Edema <ul><li>Cellular response to injury </li></ul><ul><ul><li>Primary injury </li></ul></ul><ul><ul><li>Secondary injury </li></ul></ul><ul><ul><ul><li>Hypoxic-ischemic injury </li></ul></ul></ul><ul><ul><ul><ul><li>Injured neurons have increased metabolic needs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Concurrent hypotension and hypoxemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inflammatory response </li></ul></ul></ul></ul>
  8. 10. The main factors which determine the severity of cerebral injury are: <ul><li>Distortion of the brain. </li></ul><ul><li>Mobility of brain in relation to skull and meninges. </li></ul><ul><li>Configuration of interior of skull. </li></ul><ul><li>Deceleration and acceleration. </li></ul><ul><li>The pre-existing state of brain (elderly). </li></ul>
  9. 11. Brain injury: <ul><ul><li>Concussion. </li></ul></ul><ul><ul><li>Temporary dysfunction which resolves after a variable period </li></ul></ul><ul><ul><li>Amnesia is common </li></ul></ul>
  10. 12. <ul><li>Contusion & Laceration </li></ul><ul><li>Small areas of hemorrhages </li></ul><ul><ul><li>Usually produce neurological deficits that persist for longer than 24 hours </li></ul></ul><ul><li>Diffuse axonal head injury </li></ul><ul><li>As a result of mechanical shearing following deceleration, causing disruption and tearing of axons </li></ul>
  11. 13. The Secondary pathology: <ul><li>Intracranial : </li></ul><ul><ul><li>Brain swelling, oedema. </li></ul></ul><ul><ul><li>Necrosis. Ischemia. </li></ul></ul><ul><ul><li>Hematoma. </li></ul></ul><ul><ul><li>Metabolic or endocrine disturbances. </li></ul></ul><ul><ul><li>Coning. </li></ul></ul><ul><ul><li>Coup & Counter-coup. </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Epilepsy </li></ul></ul>
  12. 14. <ul><li>Extracranial : </li></ul><ul><ul><li>Resp. failure, increase CO2. </li></ul></ul><ul><ul><li>Systemic B/P </li></ul></ul><ul><ul><li>Fluid, isotonic. </li></ul></ul><ul><ul><li>Temperature </li></ul></ul>
  13. 15. Skull fractures <ul><li>Simple fracture. </li></ul><ul><li>Comminuted linear fracture of the vault. </li></ul><ul><li>Skull base fracture. </li></ul><ul><li>Depressed fracture. by: </li></ul><ul><li>-falling objects. </li></ul><ul><li>-Assault with a heavy blunt tool. </li></ul><ul><li>-Missile injury. </li></ul><ul><li>-R.T.A </li></ul>
  14. 17. Skull base fracture <ul><li>Diagnosed on clinical bases. </li></ul><ul><li>They often result in CSF leak. </li></ul><ul><li>Rhinorrhoea </li></ul><ul><li>Anosmia </li></ul><ul><li>C-C fistula </li></ul><ul><li>Periorbital hematoma </li></ul><ul><li>CSF otorrhoea </li></ul><ul><li>Battle`s sign </li></ul>
  15. 18. <ul><li>Compound depressed fracture: </li></ul><ul><ul><li>Antibiotics. </li></ul></ul><ul><ul><li>Anti tetanus prophylaxis. </li></ul></ul><ul><ul><li>Surgery. Urgent. </li></ul></ul><ul><li>Closed depressed fracture </li></ul>
  16. 19. Closed depressed fracture Indication of surgery: <ul><li>Dural tear </li></ul><ul><li>Brain compression... (Dural venous sinuses.) </li></ul><ul><li>Cosmetic. </li></ul>
  17. 20. Missile injuries: <ul><li>Scalp injury. </li></ul><ul><li>Depressed skull fracture. </li></ul><ul><li>I.C.H. </li></ul><ul><li>Brain injury. </li></ul>
  18. 21. Management of Traumatic Head Injury <ul><li>Maximize oxygenation and ventilation </li></ul><ul><li>Support circulation / maximize cerebral perfusion pressure </li></ul><ul><li>CPP=MSP-ICP </li></ul><ul><li>Decrease intracranial pressure </li></ul><ul><li>Decrease cerebral metabolic rate </li></ul>
  19. 22. Monitoring <ul><li>Serial neurologic examinations </li></ul><ul><li>Circulation / Respiration </li></ul><ul><li>Intracranial Pressure </li></ul><ul><li>Radiologic Studies </li></ul><ul><li>Laboratory Studies </li></ul>
  20. 23. Circulatory Support: Maintain Cerebral Perfusion Pressure Number of Hypotensive Episodes Kokoska et al. (1998), Journal of Pediatric Surgery, 33 (2)
  21. 24. Lowering ICP <ul><li>Evacuate hematoma </li></ul><ul><li>Drain CSF </li></ul><ul><ul><li>Intraventricular catheters use is limited by degree of edema and ventricular effacement </li></ul></ul><ul><li>Craniotomy </li></ul><ul><ul><li>Permanence, risk of infection, questionable benefit </li></ul></ul>Brain Blood CSF Mass Bone
  22. 25. <ul><li>Reduce edema </li></ul><ul><li>Promote venous return </li></ul><ul><li>Reduce cerebral metabolic rate </li></ul><ul><li>Reduce activity associated with elevated ICP </li></ul>
  23. 26. Management on head injuries <ul><li>Minor head injury </li></ul>
  24. 27. <ul><li>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. </li></ul><ul><li>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 </li></ul>
  25. 28. Indications for admission to hospital: <ul><li>Loss of consciousness. </li></ul><ul><li>Persistent drowsiness. </li></ul><ul><li>Focal neurological deficit. </li></ul><ul><li>Skull fracture. </li></ul><ul><li>Persisting nausea & vomiting </li></ul><ul><li>Elderly & infant. </li></ul><ul><li>W. </li></ul>
  26. 29. <ul><li>Signs of deterioration : </li></ul><ul><ul><li>Becomes unusually drowsy </li></ul></ul><ul><ul><li>Develops a severe headache or stiff neck </li></ul></ul><ul><ul><li>Vomits more than once </li></ul></ul><ul><ul><li>Loses consciousness (even if brief) </li></ul></ul><ul><ul><li>Behaves abnormally </li></ul></ul>
  27. 30. <ul><li>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. </li></ul>
  28. 31. Management <ul><li>Observation. </li></ul><ul><li>Bed elevated 20. </li></ul><ul><li>Mild fluid restriction. </li></ul>
  29. 32. Severe head injury <ul><li>It depends on the patient’s neurological state and the intracranial pathology resulting from the trauma. </li></ul><ul><li>Clinical assessment and CT scan </li></ul><ul><li>Evacuation of any hematomas </li></ul>
  30. 33. <ul><li>If there is no surgical lesion, or following the operation: </li></ul><ul><ul><li>Observation and GCS chart </li></ul></ul><ul><ul><li>Decrease intracranial brain swelling </li></ul></ul><ul><ul><ul><li>Airway management </li></ul></ul></ul><ul><ul><ul><li>Elevation of the head of the bed 20º </li></ul></ul></ul><ul><ul><ul><li>Fluid and electrolyte balance </li></ul></ul></ul><ul><ul><ul><li>Blood replacement with colloid or blood and not crystalloid </li></ul></ul></ul><ul><ul><ul><li>No steroids </li></ul></ul></ul>
  31. 34. <ul><ul><li>Management of conditions resulted from head injury </li></ul></ul><ul><ul><ul><li>Severe hyponatraemia due to excessive fluid intake or inappropriate excessive secretion of ADH </li></ul></ul></ul><ul><ul><ul><li>Hypernatraemia due to inadequate fluid intake. </li></ul></ul></ul><ul><ul><ul><li>Diabetes insipidus </li></ul></ul></ul>
  32. 35. <ul><li>Temperature control, pyrexia due to hypothalamic damage or traumatic SAH or infection or from CSF leak and meningitis </li></ul>
  33. 36. <ul><ul><li>Nutrition: </li></ul></ul><ul><ul><ul><li>During the initial 2-3 days the fluid therapy will include 1.5-2 liters of 5% dextrose </li></ul></ul></ul><ul><ul><ul><li>After 3-4 days by nasogastric feeding </li></ul></ul></ul>
  34. 37. <ul><ul><li>Routine care of the unconscious patient, bowel, bladder and skin. </li></ul></ul><ul><ul><li>Intracranial monitoring in more severe cases. </li></ul></ul>