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Head trauma traumacon_2011

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Management of Head Trauma in ER

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Head trauma traumacon_2011

  1. 1. Management of Head Trauma in ER Sumit Sinha Associate Professor of Neurosurgery Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences
  2. 2. AIIMS Trauma Workshop Case Scenario ● 58-year-old male fell from a roof in a small rural town ● Initial GCS score = 12 ● On admission after 2- hour transfer, GCS score is 6 What injuries would you suspect? What are your priorities in managing this patient?
  3. 3. AIIMS Trauma Workshop Objectives ■ Initial Management- A (with C1) – B – C ■ Initial Neuro-Assessment-D- Glasgow Coma Scale Pupils ■ Immediate Neurosurgical Management CT Scan - when? Neurosurgical Consult - when? Recognition and treatment of Herniation ■ Other Considerations C-Spine, Bleeding, Extremity #, Rest of Spine ■ Pitfalls TRAUMA 2011
  4. 4. AIIMS Trauma Workshop Primary Aim of ER management ■ Prevent Secondary Brain damage at all costs TREAT AGGRESSIVELY ❖Hypo tension (MAP > 90mmHg) ❖Hypoxia (PaO2 < 60mmHg) ❖Hypoglycemia ❖Fever ❖Raised Intra-cranial Pressure ❖Seizures TRAUMA 2011
  5. 5. AIIMS Trauma Workshop Intracranial Pressure (ICP) ● Sustained increased ICP leads to decreased brain function and poor outcome ● Hypotension and low saturation adversely affect outcome 10 mm Hg = Normal >20 mm Hg = Abnormal >40 mm Hg = Severe
  6. 6. AIIMS Trauma Workshop Cerebral Perfusion Pressure Normal 90 10 80 Cushing’s Response 100 20 80 Hypotension 50 20 30 MAP – ICP = CPP CPP ≠ Cerebral Blood Flow Caution
  7. 7. AIIMS Trauma Workshop TRAUMA 2011 Concept of ICP & CPP CPP = MAP – ICP Normal : > 60 mm Hg Reduced : < 50 mmHg When will ICP ↑?? Mass Lesions - Bleeding EDH, SDH, Intraparenchymal bleed Cerebral Edema Cytotoxic, Vasogenic
  8. 8. AIIMS Trauma Workshop Autoregulation ● If autoregulation is intact, CBF is maintained constant between a mean BP of 50 to 150 mm Hg. ● In moderate or severe brain injury, autoregulation is impaired so CBF varies with mean BP. ● The injured brain is more vulnerable to episodes of hypotension, causing secondary brain injury.
  9. 9. AIIMS Trauma Workshop TRAUMA 2011 Monro-Kellie Doctrine Venous Volume Arterial Volume Brain CSF Normal State – ICP Normal Venous Volume Arterial Volume Brain CSFMASS Compensated State – ICP Normal Arterial Volume Brain Venous Volume MASS CSF Uncompensated State – ICP Raised ICP (mmHg) 35 30 25 20 15 10 5 Volume Volume-Pressure Curve Herniation Point of Decompensation TRAUMA 2011
  10. 10. AIIMS Trauma Workshop TRAUMA 2011 Initial Management – Airway with C-Spine PATENT ↓ OKAY Don’t Intubate until patient needs sedation for some other procedure THREATENED Remains Unresponsive GCS ≦ 8 (CANNOT PROTECT AIRWAY) Oral bleeding Base of Skull bleeding OBSTRUCTED Massive Maxillofacial Trauma Maxilla Mandible Associated Neck Injury * If C-Spine Injury is suspected, intubation should be performed by the most experienced person available.
  11. 11. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Breathing HYPOXIA HYPERCARBIA Maintain PaO2 > 60 mmHg Maintain Normocarbia Maintain SpO2 > 95% PaCO2 – 30-35 mmHg
  12. 12. AIIMS Trauma Workshop TRAUMA 2011 Initial Management - Circulation TREAT HYPOTENTION Maintain Mean Arterial Pressure above 90 mm Hg USE Crystalloids – RL/NS Ionotrope Infusion if needed
  13. 13. AIIMS Trauma Workshop TRAUMA 2011 Initial Neuro-Assessment ■ Key History ◻ Mechanism of Injury ◻ Response at scene → Neuro-exam at scene → Change in status ■ Note Glasgow Coma Scale (GCS 3-15) ■ Note Pupils : Size / Shape / Reaction Note the symmetry of motor Score Eye Opening Best Verbal Response Best Motor Response 6 Obeys Commands 5 Oriented Localizes Pain 4 Spontaneous Confused Flexed to Pain 3 To Speech Inappropriate Words Flexion of arms with ext of legs(decorticate) 2 To Pain Incomprehensive sounds Extension 1 None No Verbalization None
  14. 14. AIIMS Trauma Workshop TRAUMA 2011 Classification of Head Injuries A. Blunt or Penetrating B. Mild, Moderate, Severe (Based on GCS) Mild 14-15 Moderate 9-13 Severe 3-8 C. Morphology (Fracture and Intracranial)
  15. 15. AIIMS Trauma Workshop TRAUMA 2011 Mild Head Injuries ■ GCS 14-15 ■ CT if LOC, Amnesia, Severe Headache, Anticoagulation ■ Evaluate C-Spine ■ Prognosis is excellent ■ Mortality rate < 1%
  16. 16. AIIMS Trauma Workshop TRAUMA 2011 Moderate Head Injuries ■ Patients may be confused, somnolent ■ GCS 9-13 ■ Admit observe ,repeat head CT with frequent neuro checks ■ Prognosis is good ■ Mortality rate < 5 %
  17. 17. AIIMS Trauma Workshop TRAUMA 2011 Severe Head Injuries ■ GCS < 8/15 ■ Mortality rate > 40% ■ Securing of A,B,C’s highest priority ■ Early Intubation ■ Hypotension associated with twice mortality ■ Maintain Pco2 25-35 mm/Hg
  18. 18. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management ■ WHEN TO GET A CT-SCAN ? ■ Patient Comatose (GCS<13) ■ Penetrating Trauma ■ Suspect Skull # ■ CSF Leak ■ Post Trauma Seizures ■ Focal Neurological signs (Motor/Pupils) ■ WHEN TO CALL A NEUROSURGEON? ■ All of the above ■ Abnormal CT Scan
  19. 19. AIIMS Trauma Workshop TRAUMA 2011 Initial Neurosurgical Management Abnormal CT Scan
  20. 20. AIIMS Trauma Workshop TRAUMA 2011 Medical Management ■ Recognize and treat ↑ICP / Herniation Monitor : Decrease in Pulse+Ventilation+ ↑B.P. Decrease in level of Consciousness Dilated Pupil Decrease in motor power (Contralateral - Dilat pupil) ■ Cerebral Resuscitation ◻ Euventilation ◻ Intubate if (Orotracheal) if GCS<8 ◻ Mannitol Infusion 0.25-1.0 gm/Kg IV over 15 min (Not in Hypotensives) ◻ Monitor Urine Output ◻ Spine Cleared – Elevate the Head to 30°
  21. 21. AIIMS Trauma Workshop TRAUMA 2011 Other Considerations ■ Seizure Focus/Post Traumatic Seizures (2-5%) SAH, Bleed (Intracerebral, sub or extradural) Witnessed seizure Load Phenytion ≈ 11-15mg/Kg IV slow with cardiac monitoring ■ C-Spine 5%-20% of patients with severe HI will have C-spine injury 5%-10% with one spine # will have another one too Therefore C-Spine motion restriction and log-rolling till full spine cleared ■ Control of Bleeding ■ Immobilize other extremity fractures
  22. 22. AIIMS Trauma WorkshopALGORITHM FOR Mx OF MILD HEAD INJURY •History •G/E •Neurological examination •Skull X-Ray •Cervical spine X-Ray •Blood Alcohol levels CT HEAD - ideally in all but completely asymptomatic pts ADMIT 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
  23. 23. AIIMS Trauma WorkshopALGORITHM FOR Mx OF MODERATE HEAD INJURY •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
  24. 24. AIIMS Trauma WorkshopALGORITHM FOR Mx OF SEVERE HEAD INJURY •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
  25. 25. AIIMS Trauma WorkshopALGORITHM FOR Mx OF SEVERE HEAD INJURY 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
  26. 26. AIIMS Trauma Workshop Monitor ICP ICP<20 ICP>20Check PaO2, PacO2 Head/ Neck position Treat pain, Fever Recalibrate ICP system Repeat CT Surgical Mass Lesion Craniotomy No Surgical mass lesion •Mannitol •Hyperventilate •Barbiturate Coma •DC •Lobectomy
  27. 27. AIIMS Trauma Workshop TRAUMA 2011 Spine Trauma ■ C. Spine- 55% ■ Thoracic spine- 15% ■ T.L.Junction- 15% ■ L.S. spine-15% ➢ 5% of head injury pt.have spine injury
  28. 28. AIIMS Trauma Workshop TRAUMA 2011 Exclusion ■ Awake: Simple N. intact,Absence of pain, tenderness along whole spine ■ Comatose: X-rays/ C.T. scan
  29. 29. AIIMS Trauma Workshop TRAUMA 2011 Goals ■ Maintain Immobilization ■ Avoid excessive manipulation ■ Minimize second injury/insult
  30. 30. AIIMS Trauma Workshop TRAUMA 2011 ASCI- Types ■ Complete: No motor/ sensory function below the level of injury ■ Incomplete:Any motor/sensory below the level- prognosis for recovery is better ■ Peri-anal sensation may be the only sign of incomplete SCI
  31. 31. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ Loss of sympathetic outflow from S. cord ■ Loss of vasomotor tone & sympathetic supply to heart ■ Vasodilatation & pooling of blood- hypotension ■ Bradycardia- No H.R. in response to hypotension
  32. 32. AIIMS Trauma Workshop TRAUMA 2011 Neurogenic Shock ■ I.V. fluids alone may not help ■ Danger of fluid overload/P.Edema ■ Vasopressors / Atropine –significant Bradycardia
  33. 33. AIIMS Trauma Workshop TRAUMA 2011 Spinal Shock ■ Complete flaccidity & loss of reflexes ■ Gen. lasts 24- 48 hrs ■ Anal & bulbo-cavernosus –first to return
  34. 34. AIIMS Trauma Workshop TRAUMA 2011 Pitfalls ■ Never attribute neurological abnormality solely to the presence of alcohol / drugs. ■ Assume spinal Injury till ruled out ■ No naso-gastric / naso-tracheal tube if base skull # suspected ■ Treat other life threatening bleeding first ■ Systolic pressure < 90 mmHg will lead to secondary brain Injury ■ Poor Ventilation and Oxygenation will Increase
  35. 35. AIIMS Trauma Workshop TRAUMA 2011 Summary ■ Comatose patient- secure airway ■ Treat shock aggressively ■ Hypoxia and hypervolemia kill more patients than brain injury. ■ Secondary brain injury makes primary brain injury worse ■ If sedation or paralysis makes assessment difficult, then treat the patient until the brain can be assesed.
  36. 36. AIIMS Trauma Workshop TRAUMA 2011 Jai Prakash Narain Apex Trauma Center All India Institute of Medical Sciences

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