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Atls head trauma modified pdf
- 1. Committee on TraumaPresents ©ACS Head Trauma
- 2. Objectives ➢ Describe basicintracranial physiology. ➢ Recognize the importance of limiting secondary brain injury. ➢ Perform a focused neurologic exam. ➢ Stabilize and arrange for definitive care. ©ACS
- 3. ➢ Rigid, nonexpansileskull filled with brain, CSF, and blood ➢ CBF autoregulation ➢ Autoregulatory compensation disrupted by brain injury ➢ Mass effect of intracranial hemorrhage ©ACS Anatomy and physiology effects?
- 4. Monro-Kellie Doctrine ©ACS Ven. Vol. Art. Vol. Brain CSFMass Arterial Volume BrainCSF 75 mL Mass 75 mL Venous Volume Art. Vol. Brain CSF
- 5. Volume – PressureCurve ©ACS Volume of Mass 60- 55- 50- 45- 40- 35- 30- 25- 20- 15- 10- 5- ICP (mm Hg) Compensation Herniation Point of Decompensation
- 6. Intracranial Pressure (ICP) ➢10 mm Hg = Normal ➢ > 20 mm Hg = Abnormal ➢ > 40 mm Hg = Severe ➢ Many pathologic processes affect outcome ➢ Sustained ↑ ICP leads to ↓ brain function and outcome ©ACS
- 7. Cerebral Perfusion Pressure* ©ACS *CPP ≠ Cerebral Blood Flow MBP ICP CPP Normal Cushing’s Response Hypotension – = 30 90 100 50 10 80 20 20 80
- 8. Autoregulation ➢ If autoregulationis intact, CBF is maintained with a mean BP of 50 to 160 mm Hg. ➢ Moderate or severe brain injury: Autoregulation often impaired ➢ Brain more vulnerable to episodes of hypotension → secondary brain injury ©ACS
- 9. Mild Brain Injury ©ACS ➢GCS Score = 14–15 ➢ History ➢ Exclude systemic injuries ➢ Neurologic exam ➢ X-rays as indicated ➢ Alcohol / drug screens as indicated ➢ Liberal use of head CT Observe or discharge based on findings
- 10. Moderate Brain Injury ©ACS ➢GCS Score = 9–13 ➢ Initial evaluation same as for mild injury ➢ CT scan for all ➢ Admit and observe • Frequent neurologic exams • Repeat CT scan ➢ Deterioration: Manage as severe head injury
- 11. Severe Brain Injury ➢GCS Score = 3–8 ➢ Evaluate and resuscitate ➢ Intubate for airway protection ➢ Focused neurologic exam ➢ Frequent reevaluation ➢ Identify associated injuries ©ACS
- 12. Classifications of BrainInjury ©ACS By Morphology: Brain Focal Diffuse • Epidural (extradural) • Subdural • Intracerebral • Concussion • Multiple contusions • Hypoxic / ischemic injury
- 13. Diffuse Brain Injury ➢Mild concussion → Severe, ischemic insult ©ACS Normal CT Diffuse Injury
- 14. Contusion / Hematoma ➢Coup / contracoup injuries ➢ Most common: Frontal / temporal lobes ➢ CT changes usually progressive ➢ Most conscious patients: No operation ©ACS
- 15. Contusion / Hematoma ©ACS Largefrontal contusion with shift
- 16. Epidural Hematoma ➢ Associatedwith skull fracture ➢ Classic: Middle meningeal artery tear ➢ Lenticular / biconvex ➢ Lucid interval ➢ Can be rapidly fatal ➢ Early evacuation essential ©ACS
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- 18. Subdural Hematoma ➢ Venoustear / brain laceration ➢ Covers cerebral surface ➢ Morbidity / mortality due to underlying brain injury ➢ Rapid surgical evacuation recommended, especially if > 5 mm shift of midline ©ACS
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- 20. Priorities ➢ ABCDE ©ACS ➢ Minimizesecondary brain injury • Administer O2 • Maintain blood pressure (systolic > 90 mm Hg)
- 21. Focused Neurologic Exam? ➢GCS Score ©ACS Consult neurosurgeon early ➢ Pupils ➢ Lateralizing signs
- 22. Indications for CTScan? ©ACS All patients with suspicion of brain injury
- 23. Medical Management ➢ Controlledventilation ©ACS ➢ Intravenous fluids • Euvolemia • Isotonic • Goal: Paco2 at 35 mm Hg
- 24. Medical Management ©ACS ➢ Mannitol •Use with signs of tentorial herniation • Dose: 1.0 g / kg IV bolus • Consult with neurosurgeon first
- 25. Medical Management ➢ Othermedications ©ACS • Anticonvulsants • Sedation • Paralytics
- 26. Surgical Management ©ACS Scalp Injuries ➢Possible site of major blood loss ➢ Direct pressure to control bleeding ➢ Occasional temporary closure
- 27. Surgical Management ©ACS Intracranial MassLesion ➢ May be life-threatening if expanding rapidly ➢ Immediate neurosurgical consult ➢ Hyperventilation / Mannitol ➢ Damage control craniotomy: Transfer to neurosurgeon (rural / austere areas)
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- 29. Summary: What shouldI do? ➢ Maintain mean BP > 90 mm Hg ➢ Maintain Paco2 near / at 35 mm Hg ➢ Use isotonic solution for euvolemia ➢ Frequent neurologic exams ➢ Liberal use of CT scans ➢ Early neurosurgical consult ©ACS
- 30. Summary: What shouldI not do? ➢ Allow patient to become hypotensive ➢ Over-aggressively hyperventilate ➢ Use hypotonic IV fluids ➢ Use long-acting paralytics ➢ Paralyze before performing complete exam ➢ Depend on clinical exam alone ©ACS