Approach to head injured patient

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Approach to head injured patient

  1. 1. Approach to Head-Injured Patient ผศ.ดร.กรองได อุณหสูต คณะพยาบาลศาสตร์ มหาวิทยาลัยมหิดล
  2. 2. Cerebral Blood Flow (CBF) O2 concentration   CO2  CO2 vasodilator vasoconstriction dilation of cerebral vessels  CBF  BF  BF  Blood volume  Blood volume ผศ.ดร.กรองได อุณหสูต
  3. 3. Intracranial Pressure (ICP)  Cranial vault: Brain 80% + Blood 10% + Cerebrospinal fluid 10%  Normal intracranial pressure 10 mmHg  Pressure > 20 mmHg is abnormal   ICP   CBF and  cerebral perfusion “Monro-Kellie hypothesis” one volume expands… one or both of the other 2 volumes must decrease ผศ.ดร.กรองได อุณหสูต
  4. 4. Cerebral Perfusion Pressure CPP = MAP - ICP  CPP < 70 mmHg is associated with poor outcome brain injury.  A systemic mean arterial pressure is 60-180 mmHg  Cushing response = cerebral ischemia;  SBP, wide PP, reflex bradycardia   SBP, maintain CPP do not  ICP ผศ.ดร.กรองได อุณหสูต
  5. 5. Mechanism of injury Injury to the head Sudden deceleration Impact pressure wave Shearing, tensile, compressive stresses Coup injury Contrecoup injury Hemorrhage, hematomas, contusions ผศ.ดร.กรองได อุณหสูต
  6. 6. Pathophysiology Injury Primary injury Hypercarbia, cerebral edema,  ICP, hypotension, hypoxemia, Fracture, hematoma Initial damage Autoregulation  Secondary injury ผศ.ดร.กรองได อุณหสูต Compensatory mechanism
  7. 7. Pathophysiology of head injury Secondary injury Primary injury to days following the • Directly by the primary injury external force • Cellular damage; • Injury evident on P/E and CT scan • Occurs in the hours • Lack of oxygen delivery • Increased ICP ผศ.ดร.กรองได อุณหสูต
  8. 8. Secondary injuries  Hypoxia  Deceased oxygen supply increased cerebral blood volume, increasing ICP  Hypercapnia  CO2 is a potent cerebrovasodilator, increase cerebral blood flow and increased ICP  Hypotension  Overall blood loss contributes cerebral hypoperfusion  Intracranial hypertension  Cerebral edema leads to increased ICP ผศ.ดร.กรองได อุณหสูต
  9. 9. Cerebral ischemia CPP  Autoregulation Failure of autoregulation Vasoconstriction / Vasodilation • cerebral vasodilation, •  blood brain volume, • cerebral engorgement  ICP & CPP Maintain CPP • cerebral edema, •  blood brain volume, •  ICP, CPP Cerebral ischemia ผศ.ดร.กรองได อุณหสูต
  10. 10. Cerebral ischemia Cerebral ischemia  CO2 concentration /  O2 concentration CO2 dilates cerebral blood vessels  blood brain volume • • • • • Headache Nausea, vomiting Amnesia Altered LOC Restless, change in speech, loss of judgment •  ICP Early signs & symptoms Late signs ผศ.ดร.กรองได อุณหสูต • • • • • • Dilate, nonreactive pupil Unresponse to V/P Abnormal motor Change in RR  SBP Widened PP  PR
  11. 11. Categories of traumatic brain injury Focal brain Diffuse brain injury injury • Cerebral contusion, epidural, • concussion, • Diffuse axonal injury subdural, Skull fractures • Linear, depressed, comminuted, basilar intracerebral hematoma ผศ.ดร.กรองได อุณหสูต
  12. 12. Epidural hematoma  Is a focal brain injury resulting in a collection of blood between the skull & dura mater  Require immediate surgical intervention.  Signs & symptoms:  Initial  LOC followed lucid interval  rapid unconscious  Persistent  LOC  Hemiparesis or hemiplegia  Unilateral fixed or dilated pupil. ผศ.ดร.กรองได อุณหสูต
  13. 13. Subdural hematoma  Is a focal brain injury beneath the dura mater  Signs & symptoms:  Steady decline in LOC  Hemiparesis or hemiplegia  Unilateral fixed or dilated pupil. ผศ.ดร.กรองได อุณหสูต
  14. 14. Subdural hematoma Acute SDH • Occurs within 48 hrs of initial injury • Present with loss Sub acute SDH • Develops 2-24 Chronic SDH • Apearent several days after initial weeks to months injury after initial injury of consciousness • Headache, and deteriorating confusion, GCS speech deficits be developed if • Required hematoma emergent enlarges craniotomy for evacuate of the thick, coagulated blood ผศ.ดร.กรองได อุณหสูต
  15. 15. Category of head injury Mild Moderate Severe head injury head injury head injury • GCS = 13-15 • GCS = 9-12 • associated with • associated with • GCS less than or equal to 8 loss of a loss of consciousness consciousness loss of or amnesia for for up to a day consciousness less • associated with for more than 24 hours • than 1 hour ผศ.ดร.กรองได อุณหสูต
  16. 16. 1survey to head-injured patient Step 1 Step 2 ABCDE Immobilize Step 3 Brief neurological exam
  17. 17. 2survey to head-injured patient Step 1 Inspect entire head Step 6 Document Step 2 Step 5 Palpate Examine entire head cervical spine Step 3 Step 4 Inspect Determine all scalp GCS Step 7 Reassess & observe
  18. 18. Those older than 65 years of age • are at increased risk of bleeding from head injury because the aging brain shrinks away from the skull, causing the veins that bridge from the skull to the brain surface to be more easily torn.

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