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Head injury management lecture.ppt (1)

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Management of Head Injuries.

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Head injury management lecture.ppt (1)

  1. 1. Management of Head Injuries Sumit Sinha M.S; D.N.B; M.N.A.M.S; M.Ch Asstt. Professor Department of Neurosurgery JPNATC, AIIMS, New Delhi
  2. 2. ■ Major Health Hazard, 2 million injured and 1 million die/rehab/ year in India ■ 16,000 per year in Delhi. ■ Leading cause of death in multiple injured patient. ■ Tops the list of killers in young ■ Man-made preventable calamity Head Injury
  3. 3. Large number die of non- availability of timely treatment. Head Injury
  4. 4. Head Injury Definition Injury to HEAD AND BRAIN
  5. 5. Head Injury Etiology ■ Road traffic accidents ■ Fall from height ■ Assault
  6. 6. Head Injury Alcohol involved in 20% 50% fatal injury occur because of alcohol. ■ Reflexes and reaction time delayed ■ Euphoria
  7. 7. Classification Skull Fractures Focal Brain Injuries Diffuse Brain Injuries Vault Contusion Concussion Linear Coup Diffuse Axonal Depressed Contrecoup Base Open Hemorrhage / Close Hematoma Epidural Subdural Intracerebral
  8. 8. Head Injury- Neurological Examination HISTORY ■ Careful and precise ■ Time of injury and mechanism- Acceleration/ Impact injuries ■ Accident scene reconstruction ■ H/o LOC or seizures ■ h/o drug or alcohol intake
  9. 9. Head Injury- Examination VITAL SIGNS: ■ Hypertension+ Bradycardia- Intracranial hematoma ■ Hypotension + Bradycardia- Cervical spine Injury ■ Hypotension + Tachycardia- Abdo/ Thoracic Injury
  10. 10. Head Injury- Examination ■ Alternating hyperventilation and apnea- Cheyne Stokes breathing- diffuse b/l cortical dysfunction ■ Ataxic respiration- impaired cyclical rhythm- pontomedullary or medullary injury ■ Apneustic breathing- Prolonged pause at full inspiration- mid-caudal pons injury ■ Cluster Pattern- Lower medullary lesions
  11. 11. Head Injury- Examination GENERAL EXAMINATION ■ Scalp Wounds/ Fractures ■ Nasal/ ear bleeding ■ CSF oto/ rhinorrhoea- skull base fractures ■ Raccoon/ Battle’s sign ■ Facial/mandibular fractures ■ SPINAL INJURY
  12. 12. Head Injury- Examination LEVEL OF CONSCIOUSNESS ■ single most reliable indicator of severity of brain damage (Teasdale and Jennett) ■ COMA- inability to open eyes, speak and follow commands (GCS<8) ■ GCS- introduced in 1974
  13. 13. Head Injury-GCS Score in normal adults is 15 A. Eye opening Spontaneously 4 ■ To speech 3 ■ To pain 2 ■ None 1 B. Best verbal response ■ Orientated 5 ■ Confused 4 ■ Inappropr words 3 ■ Incompr sounds 2 ■ None 1 C. Best motor response ■ Obeys commands 6 ■ Localisation to pain 5 ■ Withdrawl to pain 4 ■ Spastic flexion to pain 3 ■ Extension to pain 2 ■ None 1
  14. 14. Head Injury-GCS Drawbacks: ■ No account for pupils, PR, RR and BP ■ EOM, BS reflexes not included ■ b/l eye swelling/ aphasic/ dysphasic- inaccurate
  15. 15. Head Injury-GCS Condition Self-awareness Motor function Pain perception Resp function PVS - No purposeful movements - N Locked in syndrome + Quadriplegic + N Akinetic mutism + Less movement + N Brain Death - - - -
  16. 16. Head Injury Severity based on GCS Severity GCS Mild (80%) 13-15 Moderate (10%) 9-12 Severe (10%) 3-8
  17. 17. Head Injury- Examination MEMORY ■ Immediate ■ Recent - hippocampal fornicial mamillo- thalamic tracts ■ Remote- cerebral cortex
  18. 18. Head Injury- Examination ■ AGA-inability to lay down new memories following TBI ■ RGA – memory loss to events prior to injury ■ PTA- time from injury to return of memory process- same as RGA ■ PTA- directly related to severity of injury
  19. 19. Duration of PTA Severity 0-1 hr Mild 1-24 hrs moderate 1-7 days Severe > 7 days Very Severe Head Injury- Examination Classification using PTA
  20. 20. Head Injury- Examination PUPILS UNILATERAL NONREACIVE DILATATION- TRANSTENTORIAL HERNIATION HUTCHINSON’S PUPILS
  21. 21. Head Injury- Examination PUPILS Pupillary size Light response Interpretation U/L dilated Sluggish/fixed TT herniation (III n. palsy) B/l dilated Sluggish/fixed B/l III n. Palsy Brain death U/l dilated Marcus Gunn II n. injury B/l miotic Difficult to assess Opiates, metabolic encephalopathy, pos lesion U/l miotic normal Sympathetic injury
  22. 22. Head Injury- Examination EYE MOVEMENTS Resting eye position ■ Destructive Frontal lobe lesion (ICH)- conjugate eye deviation towards the lesion ■ Deep thalamic lesions- conjugate deviation away from lesion ■ U/l Pontine lesions- conjugate deviation away from lesion ■ Spontaneous slow roving eye movements- intact brainstem
  23. 23. Head Injury- Examination EYE MOVEMENTS ■ Thalamic/ Tectal lesions- Forced downgaze ■ Cerebellar/ Brainstem lesions- skew deviation/ vertical divergence ■ Pontine tegmental lesions- Ocular bobbing ■ Oculocephalic reflex (Doll’s Eye movements)- if BS intact- eyes lag behind and rolls to opposite side, with head turning (ABSENT IN ALERT PTS AND IN BS INJURY) ■ Oculovestibular reflex (caloric testing)
  24. 24. Treatment Basis ■ Primary injury Initial damage at impact Irreversible damaged neurones Partially injured –can recover Particularly susceptible to hypoxia and ischemia Initiates cascade of metabolic changes 10 days ↓ ■ Secondary neuronal damage
  25. 25. AIM Provide optimum circumstances for recovery from damage already sustained. Prevent Secondary injury Head Injury Management
  26. 26. Head Injury Management ■ Secondary Injury ■ (Golden hour) – Hypoxia – Hypotension – ischaemia – hematoma
  27. 27. Early episodes of hypotension or hypoxia greatly increase morbidity and mortality from severe head injury Head Injury Management
  28. 28. Impaired consciousness with ALCOHOL intake -- manage along head injury lines -- rather than assuming due to alcohol Head Injury Management
  29. 29. Initial Management ■ A. Airway ■ B. Breathing ■ C. Circulation ■ D. Diagnosis
  30. 30. Head Injury Management AIRWAY Protection of airway patency from vomit, blood FB, loose teeth Intubate if ■ Airway or ventilation is inadequate ■ Patient remains unresponsive (cannot protect airway) ■ Soft tissue swelling of face/neck Aspirated /lung contusion/ pneumo/ hemothorax Suspect cervical spine injury – careful during intubation
  31. 31. Head Injury Management BREATHING Controlled ventilation (PCO 2 : 30 to 35) – Ensures normal O2 supply to brain – Prevents atelact. – expands collapsed alveoli – Combats restlessness – ↓ exhaust. resp. work. – IV Midazolam / Synchronizes Resp. with vent. – CT without artifact
  32. 32. Head Injury Management ■ At least two IV lines – 0.9% NS – Maintain BP> 100 ■ Shock is usually not related to head injury Infants Terminal situations Suspect Cervical spine injury ■ Look for other injury- viscera, # femur CIRCULATION
  33. 33. Head Injury Management Initial Assessment in < 2 mts. Define problems requiring urgent diagnostic / therapeutic action ■ Level of Consciousness (GCS) ■ Pupillary size, reaction ■ Focal Neurologic Deficits
  34. 34. Head Injury Management ■ Transportation- Cont. ABC ■ Treatment of life threatening emergency- pneumothorax etc. ■ Goal of emergency room T/T- prevent secondary insult from systemic abnormality or primary CNS injury.
  35. 35. Head Injury Management ■ Quick re-assessment ■ CT Scan – Conservative – Surgery
  36. 36. Indications for Surgery ■ Open compound wounds – CSF leak, brain come out ■ ↑ICP -in conjunction with clinical condition hematoma EDH SDH craniotomy ICH contusion refractory edema- decompressive craniotomy
  37. 37. Avoided or Corrected ■ Hypoxia ■ Hypovolemia ■ Hypotension ■ Acidosis ■ ↑ ICP ■ Seizures ■ Edema ■ Pyrexia ■ Hypo/hypernatremia ■ Hyperglycemia ■ Anaemia
  38. 38. Head Injury Management General Treatment ■ Normothermia / Mild hypothermia (340C) ■ Correct anemia – low Hb raises CBF ■ Control serum glucose ■ Maintain normal BP ■ Correct electrolyte – Hyponatremia
  39. 39. Conservative Treatment in cases with no hematoma or post op. ■ Prevention of infection – antibiotics ■ Control of pain and restlessness ■ Bladder and bowel care ■ Control of ↑ ICP ■ Anticonvulsants Head Injury Treatment
  40. 40. Sedation/ Narcotics in restless patients Can be given after CT Scan has ruled out any sizeable lesion in the brain Head Injury Management
  41. 41. •History •G/E •Neurological examination •Skull X-Ray •Cervical spine X-Ray •Blood Alcohol levels CT HEAD - ideally in all but completely asymptomatic pts ADMI T DISCHARGE •Amnesia •H/o LOC •Deteriorating consciousness •Moderate-severe headache •Alcohol/drug intoxication •Skull fracture •CSF leak •Significant ass injuries •Abnormal CT scan •Does not meet criterion for admssion •Discuss need to return if problem
  42. 42. •Initial w/u •CT SCAN IN ALL CASES ADMIT even if CT is normal Frequent neurological examinations FU CT Scan if deteriorates/before discharge If pt improves (90%) Discharge when stable If pt deteriorates (10%) Repeat CT Scan Manage as per severe HI
  43. 43. •History •Rescuscitation- ABC •Catheters •X-Rays- Cx/Chest/Skull/Abdomen/Pelvis/Extremities •G/E Emergency measures for ass injuries: •Tracheostomy •Chest tubes •Neck stabilization •Abdominal paracentesis Neurological examination
  44. 44. Intubate, Hyperventilate, Sedate, Mannitol (1g/kg) CT Scan Diffuse lesion Not Available Exploratory burr holes ICU •Monitor ICP •Elevate Head end •Sedate •Maintain Pao2 100 mm Hg •Maintain PaCo2 27-30 mm Hg ICP still high Treat ICP Surgical Lesion → OT
  45. 45. Monitor ICP ICP<20 ICP>20Check PaO2, PacO2 Head/ Neck position Treat pain, Fever Recalibrate ICP system Repeat CT Surgical Mass Lesion Craniotom y No Surgical mass lesion •Mannitol •Hyperventilate •Barbiturate Coma •DC
  46. 46. Head Injury Management SPECIFIC HEAD INJURIES
  47. 47. Extradural Haematoma Biconvex hyperdense Management ■ A surgical emergency ■ Evacuated as soon as possible ■ Excellent recovery
  48. 48. Acute Subdural Haematoma ■ Concavo- convex ■ Injuries to the cortical veins or pial artery ■ Severe TBI. ■ mortality rate very high, 60%-80%. ■ High speed ground impact injury
  49. 49. Acute Subdural Haematoma
  50. 50. Chronic Subdural Haematoma ■ Presents several weeks after a trivial trauma. ■ A simple burr hole evacuation curative. ■ May present to physician as stroke ■ May be B/L isodense
  51. 51. Intracerebral contusion/h’ge ■ If deep, small or multiple observation ICP monitoring surgery for the largest lesion ■ If large surgical evacuation. ■ May deteriorate after several days because of increase in the size / edema
  52. 52. Intracerebral contusion/h’ge
  53. 53. Evolving Intracranial hematomas 2 days later
  54. 54. Diffuse Axonal Injury Non-operable lesion
  55. 55. PRIMARY BRAIN STEM INJURY ■ 5-10% of all serious HI ■ True (Primary)/As part of DAI ■ Rent/tear/laceration/ Transection- Spinomedullary junction Pontomedullary junction Mesencephalo – pontine junction
  56. 56. PRIMARY BRAIN STEM INJURY ■ Clinical features – – Low GCS at admission – Immediate unconsciousness after accident – Persistant vegetative state – ICP < 20 ■ CT – Hemorrhage in ambient cistern – Blood along tent
  57. 57. Conclusion ■ Treatment should be PROMPT (within golden hour) so that secondary brain damage can be avoided. ■ Doctors in periphery have a responsible job.
  58. 58. Conclusion ■ Management should be done by a dedicated neurosurgical team with inputs from other specialities if required. ■ The best management plan would be a goal towards avoiding head injury.
  59. 59. Conclusion – Enforcement of traffic rules and laws – Improved illumination, vehicle design, road conditions – Not mixing drink and driving – delays reflexes and judgment

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