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Head injury

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Head injury

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Head injury

  1. 1. An Overview of Head Injury Management Eldad J. Hadar, M.D. Department of Neurosurgery
  2. 2. Checklist • Definitions – Glasgow Coma Scale – Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury – Operative – Nonoperative
  3. 3. Head Injury Guidelines • 1995 – 1st edition • 2000 – 2nd edition • 2007 – 3rd edition • Level I – Accepted principles reflecting high degree of clinical certainty • Level II – Strategies reflecting moderate degree of clinical certainty • Level III – Degree of clinical certainty not established
  4. 4. Checklist Definitions – Glasgow Coma Scale – Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury – Operative – Nonoperative
  5. 5. Glasgow Coma Scale (GCS) • Introduced by Teasdale and Jennett in 1974 • Consists of 3 clinical signs that have – Prognostic significance – Good reproducibility between observers • Scale range 3-15 • GCS < 8 has generally become accepted as representing coma / severe head injury
  6. 6. Glasgow Coma Scale (GCS)
  7. 7. Intracranial Pressure (ICP) • Normal CPP > 50 mm Hg • Autoregulatory mechanisms maintain CBF at CPP’s down to 40 mm Hg CPP = MAP – ICP
  8. 8. Intracranial Pressure (ICP) • In head injury, ICP > 20-25 mm Hg may be more detrimental than low CPP (increasing CPP may not afford protection from intracranial hypertension). • Aggressive attempts to maintain CPP > 70 should be avoided due to ARDS (Level II) • CPP<50 should be avoided (Level III)
  9. 9. Checklist • Definitions – Glasgow Coma Scale – Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury – Operative – Nonoperative
  10. 10. Mechanisms of Traumatic Brain Injury • Impact injury • Cerebral or brainstem contusions • Cerebral lacerations • Diffuse axonal injury (DAI) • Secondary injury • Intracranial hematoma • Edema • Ischemia
  11. 11. Checklist • Statistics • Definitions – Glasgow Coma Scale – Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury – Operative – Nonoperative
  12. 12. Initial Assessment History – LOC +/- – Intoxicants – Seizure – Posttraumatic amnesia • Physical Exam – GCS – Level of consciousness – Cranial nerves – Fundoscopic exam – Motor exam Start with ABC’s
  13. 13. Radiographic Evaluation • CT • Imaging study of choice for initial work-up • MRI • More helpful later in hospital course • Skull x-rays • Arteriography
  14. 14. Indications for CT • Presence of any criteria placing patient at moderate or high risk for intracranial injury • Assessment prior to general anesthesia for other procedures
  15. 15. Checklist • Definitions – Glasgow Coma Scale – Intracranial Pressure • Mechanisms of brain injury • Evaluation of head injury • Management of head injury – Operative – Nonoperative
  16. 16. Head Injury Management • Nonoperative • Seen in absence of significant intracranial mass lesion. • Typically consists of assessment and/or treatment of intracranial pressure (ICP). • Operative • Typically required when a significant intracranial mass lesion is present. • Decompressive craniectomy or brain resection less common.
  17. 17. Head Injury Management • Nonoperative • Seen in absence of significant intracranial mass lesion. • Typically consists of assessment and/or treatment of intracranial pressure (ICP). • Operative • Typically required when a significant intracranial mass lesion is present. • Decompressive craniectomy or brain resection less common.
  18. 18. Nonoperative Management • Frequent neuro checks • Frequent neuro checks • Frequent neuro checks • ICP monitoring
  19. 19. Indications for ICP Monitoring • No data to support Level I recommendation • Severe head injury (GCS 3-8) with abnormal CT (Level II) • Severe head injury (GCS 3-8) with normal CT and 2 of the following (Level III): • Age > 40 years • Unilateral or bilateral motor posturing • SBP < 90 mm Hg • Mild-moderate head injury at discretion of treating physician
  20. 20. Indications for ICP Monitoring • Loss of neurological examination • Sedation • General anesthesia
  21. 21. Clinical Scenario • 20 y.o. male in MVA – Intubated • Score 1T – Eyes open to pain • Score 2 – Briskly localizes • Score 5 • TotalGCS 8T
  22. 22. ICP Monitor
  23. 23. Preferred method in Guidelines
  24. 24. Therapy for Intracranial Hypertension • First tier • Positioning • Ventricular drainage • Osmotic diuresis • Hyperventilation (Level III – temporizing measure) • Second tier • Sedation • Neuromuscular blockade • Hypothermia • Barbiturate coma • Glucocorticoids not recommended (Level I)
  25. 25. Head Injury Management • Nonoperative • Seen in absence of significant intracranial mass lesion. • Typically consists of assessment and/or treatment of intracranial pressure (ICP). • Operative • Typically required when a significant intracranial mass lesion is present. • Decompressive craniectomy or brain resection less common.
  26. 26. Operative Management • Types of mass lesions • Epidural hematoma • Subdural hematoma • Cerebral contusion • Decompressive craniectomy/brain resection
  27. 27. Epidural Hematoma (EDH) • 1% of head trauma admissions • Male: Female = 4:1 • Source of bleeding is arterial in 85% of cases (middle meningeal artery) • Mortality ranges from 5-10% with optimal management • Neurological injury caused by secondary mechanisms
  28. 28. Subdural Hematoma (SDH) • About twice as common as EDH • Mortality 50-90% • Impact injury much higher than with EDH • Often associated brain injury • Two common sources of bleeding • Tearing of bridging veins • Cortical laceration
  29. 29. Cerebral Contusion • Often little mass effect • Not often operative
  30. 30. Pre-op Post-op Hemicraniectomy
  31. 31. Key Points • 2 mechanisms of brain injury • Impact injury • Secondary injury • GCS < 8 has generally become accepted as representing coma / severe head injury • CT is generally the imaging study of choice in the acute assessment of head injury • Operative and nonoperative strategies are generally aimed at reducing mass effect and, therefore, reducing ICP • Nothing beats a neuro exam.
  32. 32. Our views have increased the mark of the 25,000 Thank you viewers Looking forward to franchise, collaboration, partners. 36
  33. 33. This platform has been started by Parveen Kumar Chadha with the vision that nobody should suffer the way he has suffered because of lack and improper healthcare facilities in India. We need lots of funds manpower etc. to make this vision a reality please contact us. Join us as a member for a noble cause. 37
  34. 34. Contact us:- 011-25464531, 9818569476 E-mail:- nursingnursing@yahoo.in 38 Saxbee Consultants Details :-www.parveenchadha.com
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Head injury

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