Craniocerebral InjuryCraniocerebral Injury
Ranjit PandeyRanjit Pandey
PharmacistPharmacist
ranjitpandey17@gmail.comranjitp...
Who should lead the Management Team ?Who should lead the Management Team ?
Head Injuries
 19701970 : General Surgeon –: G...
LandmarkLandmark StudyStudy
Jennett W.B, Teasdale G. M, Galbraith S. L, et al:Jennett W.B, Teasdale G. M, Galbraith S. L, ...
Severe head injuries in three countriesSevere head injuries in three countries
Jennett BJennett B,, Teasdale GTeasdale G,,...
IncidenceIncidence
 AdmissionAdmission 300/100,000300/100,000
 MortalityMortality 9 / 100,0009 / 100,000
Craniocerebral ...
Sex RatioSex Ratio
Male
66%
Female
34%
Craniocerebral Injury
Shrestha D. B., Study of Head Injuries at Bir Hospital, Augus...
Age DistributionAge Distribution
58.1%
39.5%
2.4%
0
20
40
60
80
100
120
140
< 15 15 - 60 > 60
Craniocerebral Injury
Shrest...
AetiologyAetiology
Craniocerebral Injury
RTA
36%
Fall
57%
Assault
5%
Misc.
2%
Shrestha D. B., Study of Head Injuries at Bi...
PathologyPathology
Impact damageImpact damage
Contusion / lascerationContusion / lasceration
Diffuse axonal injuryDiffuse...
Cerebral swellingCerebral swelling
VasodilatationVasodilatation
OedemaOedema
Cerebral ischaemiaCerebral ischaemia
Hypoxi...
Influence of Hypotension and HypoxiaInfluence of Hypotension and Hypoxia
Patient Outcome( %)Patient Outcome( %)
Secondary ...
AirwayAirway
BreathingBreathing
CirculationCirculation
Chest / Abdomen InjuryChest / Abdomen Injury
Head / Spinal Inj...
Neurological AssessmentNeurological Assessment
HistoryHistory
Duration of loss of consciousnessDuration of loss of consci...
Glasgow Coma ScaleGlasgow Coma Scale
 Eye openingEye opening (4)(4)
 Best motor responseBest motor response (6)(6)
 Ver...
InvestigationsInvestigations
X-ray skullX-ray skull
OrientatedOrientated Not orientatedNot orientated
No fractureNo fract...
Indication for skull X -RayIndication for skull X -Ray
 Loss of consciousness or amnesiaLoss of consciousness or amnesia
...
Indication for Cranial CTIndication for Cranial CT
 Skull fracture with GCS<8 even afterSkull fracture with GCS<8 even af...
Conservative ManagementConservative Management
OxygenationOxygenation
Electrolytes monitoringElectrolytes monitoring
Ce...
Indication for VentilationIndication for Ventilation
 Poor blood gases.Poor blood gases.
 Spontaneous hyperventilation.S...
Surgical ManagementSurgical Management
HaematomaHaematoma
EvacuationEvacuation
ObservationObservation
Elevation of depre...
Intracranial Contents by Volume
Glia 700 - 900 ml
Neurones 500 - 700 ml
Blood 100 - 150 ml
CSF 100 - 150 ml
ECF < 75 ml
Intracranial Pressure Volume Response
0
10
50
Cerebral Perfusion PressureCerebral Perfusion Pressure
Based ManagementBased Management
↓↓ CPP, BP &CPP, BP & ↑↑ ICPICP
C...
Delayed EffectsDelayed Effects
EpilepsyEpilepsy
EarlyEarly
LateLate
CSF leakCSF leak
Dural repairDural repair Leak > 7 d...
Controversies in Head InjuryControversies in Head Injury
 SteroidsSteroids
 Anti convulsantAnti convulsant
 Antibiotics...
Cranial Nerve InjuryCranial Nerve Injury
RecoversRecovers I, III, IV, VI, late VIII, III, IV, VI, late VII
Seldom recove...
Outcome after Severe InjuryOutcome after Severe Injury
Glasgow Outcome ScoreGlasgow Outcome Score
FavourableFavourable 40...
Chronic Subdural HaematomaChronic Subdural Haematoma
Predisposing factorsPredisposing factors
Cerebral atrophyCerebral at...
ConclusionConclusion
 Head injuries - heterogeneous group. Research andHead injuries - heterogeneous group. Research and
...
Head injury
Head injury
Head injury
Head injury
Head injury
Head injury
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Head injury

  1. 1. Craniocerebral InjuryCraniocerebral Injury Ranjit PandeyRanjit Pandey PharmacistPharmacist ranjitpandey17@gmail.comranjitpandey17@gmail.com
  2. 2. Who should lead the Management Team ?Who should lead the Management Team ? Head Injuries  19701970 : General Surgeon –: General Surgeon – Neurosurgeon & AnaesthetistNeurosurgeon & Anaesthetist  1970- 19901970- 1990 : Neurosurgeon- Anaesthetist: Neurosurgeon- Anaesthetist  2000-2000- : Intensivist- Neurosurgeon: Intensivist- Neurosurgeon
  3. 3. LandmarkLandmark StudyStudy Jennett W.B, Teasdale G. M, Galbraith S. L, et al:Jennett W.B, Teasdale G. M, Galbraith S. L, et al: Severe head injuries in three countriesSevere head injuries in three countries  Baseline studyBaseline study  Severe head injury mortality 49%Severe head injury mortality 49% J Neurol Neurosurg Psychiatry 1977, 40 : 291- 298 Head Injuries
  4. 4. Severe head injuries in three countriesSevere head injuries in three countries Jennett BJennett B,, Teasdale GTeasdale G,, Galbraith SGalbraith S,, Pickard JPickard J,, Grant HGrant H,, Braakman RBraakman R,, Avezaat CAvezaat C,, Maas AMaas A,, Minderhoud JMinderhoud J,, Vecht CJVecht CJ,, Heiden JHeiden J,, Small RSmall R,, Caton WCaton W,, Kurze TKurze T..  Methods for assessing early characteristics and lateMethods for assessing early characteristics and late outcome after severe head injury have been devised andoutcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland,applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarityNetherlands, and USA). There was a close similarity between the initial features of patients in the threebetween the initial features of patients in the three series; in spite of differences on organization of care andseries; in spite of differences on organization of care and in details of management , the mortality was exactly thein details of management , the mortality was exactly the same in each country. This data bank of cases (which issame in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcomestill being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.in new cases, and for setting up trials of management. PMID: 886355 [PubMed - indexed for MEDLINE]PMID: 886355 [PubMed - indexed for MEDLINE]
  5. 5. IncidenceIncidence  AdmissionAdmission 300/100,000300/100,000  MortalityMortality 9 / 100,0009 / 100,000 Craniocerebral Injury Population based study in United Kingdom
  6. 6. Sex RatioSex Ratio Male 66% Female 34% Craniocerebral Injury Shrestha D. B., Study of Head Injuries at Bir Hospital, August 1996.
  7. 7. Age DistributionAge Distribution 58.1% 39.5% 2.4% 0 20 40 60 80 100 120 140 < 15 15 - 60 > 60 Craniocerebral Injury Shrestha D. B., Study of Head Injuries at Bir Hospital, August 1996.
  8. 8. AetiologyAetiology Craniocerebral Injury RTA 36% Fall 57% Assault 5% Misc. 2% Shrestha D. B., Study of Head Injuries at Bir Hospital, August 1996.
  9. 9. PathologyPathology Impact damageImpact damage Contusion / lascerationContusion / lasceration Diffuse axonal injuryDiffuse axonal injury Secondary brain damageSecondary brain damage HaematomaHaematoma ExtraduralExtradural 27%27% SubduralSubdural 26%26% Burst lobeBurst lobe 38%38% Extra + IntraduralExtra + Intradural 8%8% Craniocerebral Injury
  10. 10. Cerebral swellingCerebral swelling VasodilatationVasodilatation OedemaOedema Cerebral ischaemiaCerebral ischaemia HypoxiaHypoxia Impaired perfusionImpaired perfusion HerniationHerniation Lateral tentorialLateral tentorial Central tentorialCentral tentorial TonsillarTonsillar Electrolytes imbalanceElectrolytes imbalance InfectionInfection PathologyPathology contd…contd… Craniocerebral Injury
  11. 11. Influence of Hypotension and HypoxiaInfluence of Hypotension and Hypoxia Patient Outcome( %)Patient Outcome( %) Secondary No. of patients TotalSecondary No. of patients Total Good or Severe orGood or Severe or insultinsult patients,%patients,% moderate vegetative Deadmoderate vegetative Dead Total casesTotal cases 699699 100100 42.942.9 20.5 36.620.5 36.6 NeitherNeither 456456 65.265.2 51.1 21.9 27.051.1 21.9 27.0 HypoxiaHypoxia 7878 11.211.2 44.9 21.8 33.344.9 21.8 33.3 HypotensionHypotension 113113 16.216.2 25.725.7 14.1 60.214.1 60.2 BothBoth 5252 7.47.4 5.8 19.2 75.05.8 19.2 75.0
  12. 12. AirwayAirway BreathingBreathing CirculationCirculation Chest / Abdomen InjuryChest / Abdomen Injury Head / Spinal InjuryHead / Spinal Injury Limbs InjuryLimbs Injury Clinical AssessmentClinical Assessment Craniocerebral Injury
  13. 13. Neurological AssessmentNeurological Assessment HistoryHistory Duration of loss of consciousnessDuration of loss of consciousness Duration of post traumatic amnesiaDuration of post traumatic amnesia Cause & circumstance of the injuryCause & circumstance of the injury Persistent headache / vomitingPersistent headache / vomiting ExaminationExamination Glasgow Coma ScaleGlasgow Coma Scale Pupillary responsePupillary response Focal signsFocal signs Local injuryLocal injury Eye movementsEye movements Cushing’s TriadCushing’s Triad Craniocerebral Injury
  14. 14. Glasgow Coma ScaleGlasgow Coma Scale  Eye openingEye opening (4)(4)  Best motor responseBest motor response (6)(6)  Verbal responseVerbal response (5)(5) Teasdale and Jennett, Lancet 2: 81-84, 1974
  15. 15. InvestigationsInvestigations X-ray skullX-ray skull OrientatedOrientated Not orientatedNot orientated No fractureNo fracture 1:60001:6000 1:1201:120 FractureFracture 1:321:32 1:41:4 CT scan of headCT scan of head Extradural haematomaExtradural haematoma Subdural haematomaSubdural haematoma Burst lobeBurst lobe Diffuse axonal injuryDiffuse axonal injury Craniocerebral Injury
  16. 16. Indication for skull X -RayIndication for skull X -Ray  Loss of consciousness or amnesiaLoss of consciousness or amnesia  Neurological symptoms or signsNeurological symptoms or signs  CSF leak from nose or earsCSF leak from nose or ears  Scalp woundScalp wound Head Injuries
  17. 17. Indication for Cranial CTIndication for Cranial CT  Skull fracture with GCS<8 even afterSkull fracture with GCS<8 even after resusciationresusciation  Deterioration in the level of consciousnessDeterioration in the level of consciousness  Persistent altered sensorium or neuro deficitPersistent altered sensorium or neuro deficit > 8 hrs> 8 hrs  Depressed vault or suspected basal fracture.Depressed vault or suspected basal fracture.  Penetrating injuryPenetrating injury  Rising BP and falling pulse rateRising BP and falling pulse rate Head Injuries
  18. 18. Conservative ManagementConservative Management OxygenationOxygenation Electrolytes monitoringElectrolytes monitoring Cerebral oedemaCerebral oedema InfectionInfection HypovolaemiaHypovolaemia AnticonvulsantsAnticonvulsants Brain protective agentsBrain protective agents Craniocerebral Injury
  19. 19. Indication for VentilationIndication for Ventilation  Poor blood gases.Poor blood gases.  Spontaneous hyperventilation.Spontaneous hyperventilation.  Hyperthermia with spontaneous posturing.Hyperthermia with spontaneous posturing.  Basal fracture with profuse bleeding inBasal fracture with profuse bleeding in unconscious patients.unconscious patients.  Brain swelling at the end of craniotomy.Brain swelling at the end of craniotomy.  Electively to reduce ICP.Electively to reduce ICP. Head Injuries
  20. 20. Surgical ManagementSurgical Management HaematomaHaematoma EvacuationEvacuation ObservationObservation Elevation of depressed fractureElevation of depressed fracture SimpleSimple CompoundCompound Debridement of scalp injuryDebridement of scalp injury Craniocerebral Injury
  21. 21. Intracranial Contents by Volume Glia 700 - 900 ml Neurones 500 - 700 ml Blood 100 - 150 ml CSF 100 - 150 ml ECF < 75 ml
  22. 22. Intracranial Pressure Volume Response 0 10 50
  23. 23. Cerebral Perfusion PressureCerebral Perfusion Pressure Based ManagementBased Management ↓↓ CPP, BP &CPP, BP & ↑↑ ICPICP CVP LowCVP Low Plasma expanderPlasma expander NormalNormal Inotropic agentsInotropic agents ↓↓ CPP, normal BP &CPP, normal BP & ↑↑ ICPICP SJvOSJvO22 NormalNormal (60-75%)(60-75%) MannitolMannitol HighHigh (> 75%)(> 75%) HyperventilationHyperventilation LowLow (< 60%)(< 60%) HypnoticsHypnotics Craniocerebral Injury
  24. 24. Delayed EffectsDelayed Effects EpilepsyEpilepsy EarlyEarly LateLate CSF leakCSF leak Dural repairDural repair Leak > 7 daysLeak > 7 days Late meningitisLate meningitis Postconcussional symptomsPostconcussional symptoms Cumulative brain damageCumulative brain damage Craniocerebral Injury
  25. 25. Controversies in Head InjuryControversies in Head Injury  SteroidsSteroids  Anti convulsantAnti convulsant  AntibioticsAntibiotics  Burr holeBurr hole
  26. 26. Cranial Nerve InjuryCranial Nerve Injury RecoversRecovers I, III, IV, VI, late VIII, III, IV, VI, late VII Seldom recoversSeldom recovers II, V, early VIIII, V, early VII Variable recoveryVariable recovery VIIIVIII Seldom surviveSeldom survive IX, X, XI, XIIIX, X, XI, XII Craniocerebral Injury
  27. 27. Outcome after Severe InjuryOutcome after Severe Injury Glasgow Outcome ScoreGlasgow Outcome Score FavourableFavourable 40%40% Good recoveryGood recovery Moderate disabilityModerate disability UnfavourableUnfavourable Severe disabilitySevere disability 18%18% VegetativeVegetative 2 %2 % DeathDeath 40%40% Prognostic factorsPrognostic factors Duration of comaDuration of coma Glasgow Coma ScaleGlasgow Coma Scale Pupillary responsePupillary response AgeAge Craniocerebral Injury
  28. 28. Chronic Subdural HaematomaChronic Subdural Haematoma Predisposing factorsPredisposing factors Cerebral atrophyCerebral atrophy Low CSF pressureLow CSF pressure AlcoholismAlcoholism Coagulation disorderCoagulation disorder ManagementManagement AdultAdult EvacuationEvacuation SteroidsSteroids InfantsInfants AspirationAspiration ShuntShunt Craniocerebral Injury
  29. 29. ConclusionConclusion  Head injuries - heterogeneous group. Research andHead injuries - heterogeneous group. Research and therapy to be targeted to the specific subgroups.therapy to be targeted to the specific subgroups.  No single magic bullet to prevent secondaryNo single magic bullet to prevent secondary neuronal damage.neuronal damage.  Future challenge - find the appropriate dose, timingFuture challenge - find the appropriate dose, timing and combination of multiple neuroprotective agents.and combination of multiple neuroprotective agents.

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