head trauma part 2 powerpoint presentation

head trauma part 2 powerpoint presentation

1. Intracranial hemorrhages its Management PRESENTED BY – DR MANDAR JAIN PG 1 EMERGENCY MEDICINE RKDF MEDICAL COLLEGE

2. Intracranial Hemorrhage Extra- axial hemorrhage Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intra-axial hemorrhage Intra- parenchymal hemorrhage Intra-ventricular hemorrhage

3. Epidural hematoma Results from bleeding between the dura and the inner surface of the skull MC type of traumatic Intracranial bleed, rarely occurs spontaneously A neurologic emergency Bleed is Venous or arterial origin

4. Epidural hematoma Source of Bleed : Tempero parietal locus (most likely) - Middle meningeal artery Frontal locus - anterior ethmoidal artery Occipital locus - transverse  or sigmoid sinuses Vertex locus - superior sagittal sinus Clinical Features: LOC>>> Lucid Interval >> unconsciousness s/s of raised ICP Focal neurological deficit s/s of cerebral herniation

5. Subdural hematoma Occurs from bleeding between the dura mater and arachnoid layer of the meningeal covering of the brain Source of bleed: Bridging veins; May be caused by an arterial hemorrhage Much slower to develop into a mass large enough to produce symptoms. Cause: Acceleration-deceleration injury, direct trauma, Risk factors: Elderly, dementia, alcoholics, shaken baby syndrome, pts on anticoagulants

6. Subdural hematoma Acute subdural hematoma(<72hrs) High mortality Associated with major direct trauma (Shearing Forces) Clinical Features : Headache, fluctuating LOC, confusion, dilated fixed pupil, deviated gaze CT scan: hyperdense

7. Subdural hematoma Subacute subdural hematoma Occurs within 4-21 days of the injury Failure to regain consciousness may be an indicator CT scan: Isodense or hypodense Chronic subdural hematoma(>3wks) Develops over weeks or months after a seemingly minor head injury, probably from repeat minor bleeds CT scan : hypodense

8. Epidural and Subdural Hematomas Hematoma type Epidural Subdural Location Between the  skull and the  dura Between the  dura  and the  arachnoid Involved vessel Temperoparietal (most likely) -  Middle meningeal artery Frontal -  anterior ethmoidal artery Occipital -  transverse or  sigmoid sinuses Vertex -  superior sagittal sinus Bridging veins Symptoms Lucid interval  followed by  unconsciousness Gradually increasing  headache  and  confusion CT  appearance Biconvex lens- limited by suture lines Crescent shaped- crosses suture lines Fig. 55-15

9. Subarachnoid Hemorrhage Causes : Rupture of Berry aneurism(MCC) Trauma (fracture at the base of the skull leading to internal carotid aneurysm) Amyloid angiopathy Blood dyscrasias Vasculitis Clinical Features: Explosive or thunderclap headache, “worst headache of my life”, nausea and vomiting, decreased LOC or coma. Signs of meningeal irritation

10. Intracerebral Hemorrhage (ICH) Intracranial hemorrhage is hemorrhage that occurs within the brain tissue itself; an intra-axial hemorrhage. Two main types: Intraparencymal hemorrahge - ICH extending into brain parenchyma; MCC- HTNsive vasculopathy Intra-ventricular hemorrhage - ICH extending into ventricles; MCC –trauma Causes : Hypertensive vasculopathy (70-80%) Ruptured AVM Trauma Blood dyscracias

11. Intracerebral Hemorrhage (ICH) Clinical presentation: Rapidly progressive severe headache, building over several minutes, often accompanied by focal neurological deficits, nausea and vomiting, decreased level of consciousness. S/S depend site of hemorrhage : Basal ganglia/internal capsule - hemiparesis , dysphasia Cerebellum - ataxia, vertigo Pons - cranial nerve deficits, coma Cerebral cortex - hemiparesis , hemisensory loss, hemianopsia , dysphasia

12. Complications Neurological deficits or death Seizures Obstructive Hydrocephalus Spasticity Urinary complications Aspiration pneumonia Cushing’s ulcer Neuropathic pain Deep venous thrombosis Pulmonary emboli Cerebral herniation

13. Cerebral Herniation Brain herniation  is a deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull Brain herniation represents mechanical displacement of normal brain relative to another anatomic region secondary to mass effect from traumatic, neoplastic , ischemic, or infectious etiologies.

14. Cingulate Herniation The most common type, the innermost part of the frontal lobe is scraped under part of the  falx cerebri , the dura mater at the top of the head between the two hemispheres of the brain. Cingulate herniation can be caused when one hemisphere swells and pushes the  cingulate gyrus by the falx cerebri . Cingulate herniation is frequently believed to be a precursor to other types of herniation

15. Uncal Herniation Common subtype of cerebral herniation following raised ICP Innermost part of the temporal lobe, the  uncus , can be squeezed so much that it moves towards the  tentorium and puts pressure on the brainstem, most notably the midbrain Clinical feature: Compression of I/L CN III- I/L fixed dilted pupil Compression of I/L PCA- C/L homonymous hemianopsia Compression of C/L crus cerebri - I/L hemi paresis Duret hemorrhage

16. Diagnostic Studies CT scan – A GCS score less than 15 after blunt head trauma warrants a patient for consideration of an urgent CT scan.

17. CT findings Fig. 55-15 Epidural Hematoma Subdural Hematoma

18. CT findings Fig. 55-15 Subarachnoid hemorrhage Intracerebral hematoma

19. Diagnostic Studies MRI – superior for demonstrating the size of an acute subdural hematoma. Cerebral angiogram if hemorrhage is confirmed (not necessary in case of classic hypertensive hemorrhage) Cervical spine X-ray EEG Lumbar Puncture

20. Management 1) Supportive Measures : Endotracheal intubation for patients with decreased level of consciousness and poor airway protection. Cautiously lower blood pressure to a MAP less than 130 mm Hg, but avoid excessive hypotension. [10] Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan. Maintain euvolemia , using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema Avoid hyperthermia. Facilitate transfer to the operating room or ICU.

21. Management 2) Decrease cerebral edema : Modest passive hyperventilation to reduce PaCO2 Mannitol , 0.5-1.0 gm/kg slow iv push Elevate head 20-30 degrees, avoid any neck vein compression Sedate and paralyze if necessary with morphine and vecuronium (struggling, coughing etc will elevate intracranial pressure)

22. Management 3) Surgical Evacuation of hematoma: No surgical intervention if collection <10ml Indication of surgical decompression: The GCS score decreases by 2 or more points between the time of injury and hospital evaluation The patient presents with fixed and dilated pupils The intracranial pressure (ICP) exceeds 20 mm Hg Exception : In Subdural hematoma with GCS=15- hematoma >10mm or >5mm midline shift ---- requires Surgical decompression SAH: when a cerebral aneurysm  is identified on angiography, clipping and coiling is done to prevent re-bleed

23. Management Surgical Decompression contd.. Types: Burr-hole Craniotomy- bone flap is temporarily removed from the skull to access the brain Craniectomy – in which the skull flap is not immediately replaced, allowing the brain to swell, thus reducing intracranial pressure Cranioplasty -   surgical repair of a defect or deformity of a skull. 

24. Management 4) Medical therapy: Antihypertensives - reduce blood pressure to prevent exacerbation of intracerebral hemorrhage in hypertensive encephalopathy. Eg Nicardipine , labetolol ; CCB help relieve vasospasm in SAH and decrease further damage Diuretics - Mannitol , CAI Anticonvulsants – reduce frequency of seizures and prophylaxis of seizures eg : Fosphenytoin Antipyretics- to Rx fever and pain relief eg : Acetaminophene Antidote- VitK /FFP for warfarin overdose ; protamine for heparin overdose Antacids- prophylaxis for Cushing’s gastric ulcer eg : Famotidin Glucocortecoids may help reduce the head and neck ache caused by the irritative effect of the subarachnoid blood.

25. Preventive Measures Health Promotion Prevent car and motorcycle accidents To Wear safety helmets

26. Rehabilitation Ambulatory and Home Care Nutrition Bowel and bladder management Spasticity Dysphagia Seizure disorders Family participation and education

27. THANK YOU