HEAD TRAUMA.pptx read it well because it

Clinical features
❖ The range of possible symptoms caused by UTI is extremely broad,
from no symptoms to symptoms referable to the lower urinary tract
(e.g. dysuria and frequency), to symptoms indicative of an upper UTI
(e.g. loin pain, fever, chills and costo-vertebral angle tenderness), to
full-blown urosepsis.
❖ Lower UTI (Cystitis)
▪ Commonly dysuria, frequent urination and urgency;
Occasionally, gross hematuria, Suprapubic pain
▪ Elderly people may have nonspecific symptoms only (like
chronic dysuria or urinary incontinence, mental status changes,
abdominal pain and decreased eating or drinking)
▪ Chronic nocturia or chronic incontinence, general malaise, and
cloudy or malodorous urine are nonspecific features that should
not routinely swift for cystitis evaluation and treatment.
❖ Upper UTI (pyelonephritis)
▪ dysuria, frequent urination and urgency, hematuria
▪ Systemic symptoms like fever, chills, rigors, and marked fatigue
or malaise beyond baseline, nausea, vomiting
▪ Suprapubic pain
▪ Costovertebral angle tenderness; flank pain
▪ Pelvic or perineal pain (in men),
▪ Elevated WBC
▪ Elderly people may have nonspecific symptoms only (like
mental status changes, abdominal pain and decreased eating
or drinking)
Investigations and diagnosis
➢ Clinical
☛ signs and symptoms and urinalysis are the common
diagnostic methods
☛ Digital rectal examination (DRE): For men with symptoms of
pelvic or perineal pain, DRE might be warranted to evaluate a
tender or edematous prostate, suggesting acute prostatitisClinical features
❖ The range of possible symptoms caused by UTI is extremely broad,
from no symptoms to symptoms referable to the lower urinary tract
(e.g. dysuria and frequency), to symptoms indicative of an upper UTI
(e.g. loin pain, fever, chills and costo-vertebral angle tenderness), to
full-blown urosepsis.
❖ Lower UTI (Cystitis)
▪ Commonly dysuria, frequent urination and urgency;
Occasionally, gross hematuria, Suprapubic pain
▪ Elderly people may have nonspecific symptoms only (like
chronic dysuria or urinary incontinence, mental status changes,
abdominal pain and decreased eating or drinking)
▪ Chronic nocturia or chronic incontinence, general malaise, and
cloudy or malodorous urine are nonspecific features that should
not routinely swift for cystitis evaluation and treatment.
❖ Upper UTI (pyelonephritis)
▪ dysuria, frequent urination and urgency, hematuria
▪ Systemic symptoms like fever, chills, rigors, and marked fatigue
or malaise beyond baseline, nausea, vomiting
▪ Suprapubic pain
▪ Costovertebral angle tenderness; flank pain
▪ Pelvic or perineal pain (in men),
▪ Elevated WBC
▪ Elderly people may have nonspecific symptoms only (like
mental status changes, abdominal pain and decreased eating
or drinking)
Investigations and diagnosis
➢ Clinical
☛ signs and symptoms and urinalysis are the common
diagnostic methods
☛ Digital rectal examination (DRE): For men with symptoms of
pe

1. HEAD TRAUMA

2. Sections Introduction to head and facial Injuries Anatomy and physiology of the head Assessment of head and facial injuries Head and facial injury Management

3. Head Injury Number One Killer in Trauma 25% of all trauma deaths 50% of all deaths from MVC 200,000 people in the US live with the disability caused by these injuries One in eight for men and one in fourteen in women death

4. 150.000 trauma deaths per year in the US 50% due to fatal head injury Up to half of all head-injured patients admitted to hospital remain disabled at one year

5. Scalp Cranium Meninges Cerebrospinal Fluid Brain CNS Circulation Cranial Nerves Ascending Reticular Activating System Anatomy of head and face

6. Scalp Strong Flexible mass of Skin Fascia Muscular Tissue Highly Vascular Hair provides Insulation Structures Beneath Galea Aponeurotica Fibrous connective sheath Subaponeurotica (Areolar) Tissue Permits venous blood flow from the dural sinuses to the venous vessels of scalp Emissary Veins: Potential route for Infection Anatomy…….

7. Recalling Structures of the Scalp S - skin C - connective tissue A - aponeurotica L - layer of areolar tissue P - periosteum of skull Anatomy…….

8. Skull comprised of Facial bones Cranium Vault for the brain Strong, light, rigid, spherical bone Unyielding to increased intracranial pressure (ICP) Bones Frontal Parietal Occipital Temporal Ethmoid Sphenoid Anatomy……………

9. Parietal Suture Line Frontal Temporal Orbits Maxillae Mandible Temporal Mandibular Joint Occiptal Nasal Bones Zygomatic Arch Sphenoid Foramen Magnum (Hole in Base) Cranium

10. Facial Bones Zygoma Prominent bone of the cheek Protects eyes Attachment for muscles controlling eye & jaw movement Maxilla Upper jaw Supports the nasal bone Provides lower border of orbit Mandible Jaw bone Nasal Bones Anatomy……..

11. Meninges Protective mechanism for the CNS Dura Mater Layers Outer: Cranium’s inner periosteum Inner: Dural Layer Between: Dural Sinuses: Venous drains for brain Provides continuous connective tissue Forms partial structural divisions Falx cerebri Tentorium cerebelli Falx cerebelli Large arteries above Provide blood flow to the surface of the brain Anatomy………….

12. Meninges Pia Mater Closest to brain and spinal cord Delicate tissue Covers all areas of brain and spinal cord Very Vascular Supply superficial areas of brain Arachnoid Membrane “Spider-like” Covers inner dura Suspends brain in cranial cavity Collagen & Elastin fibers Subarachnoid Space beneath CSF Cushions brain Anatomy……….

13. Cerebrospinal Fluid Clear, colorless fluid Comprised of Water Protein Salts Cushions CNS Made in largest two ventricles of brain Medium for nutrients and waste products to diffuse into and out of brain Anatomy………

14. Brain Occupies 80% of cranium Comprised of 3 Major Structures Cerebrum Cerebellum Brainstem High metabolic rate Receives 15% of cardiac output Consumes 20% of body’s oxygen Requires constant circulation IF Blood supply stops Unconscious within 10 seconds Death in 4-6 minutes Anatomy……….

15. Cerebrum Falx Cerebri Divides cerebrum into right and left hemispheres Central Sulcus Fissure splits cerebrum into frontal and parietal lobes Each hemisphere controls the opposite side of the body Tentorium Fibrous sheet within occipital region Brainstem perforates thru incisura tentorri cerebelli Oculomotor Nerve (CN-III) travels along Controls pupil size Compression results in pupillary disturbances Anatomy …….

16. CNS Circulation Arterial Four Major Arteries 2 Internal Carotid Arteries From the common carotid 2 Vertebral Arteries Circle of Willis Internal Carotids and Vertebral Arteries Encircle the base of the brain Venous Venous drainage occurs through bridging veins Bridge Dural Sinuses Drain into internal jugular veins Anatomy……….

17. Anatomy……

18. Blood-Brain Barrier Less permeable than elsewhere in body DO NOT allow flow of interstitial proteins Very protected environment Blood acts as irritant resulting in cerebral edema Anatomy………

19. Cranial Nerves 12 pair with distinct pathways Senses, facial innervations, & body function control Ascending Reticular Activation System Tract of neurons in upper midbrain, pons, and medulla Responsible for sleep-wake cycle Monitors input stimulation Regulates body functions Respiration Heart Rate Peripheral Vascular Resistance Injury may result in prolonged unconsciousness Anatomy………

20. Face Muscles M Chewing muscles M Posterior palate and pharynx M Face Muscles M Sight S Optic II Pupil Const, Rectus & Obliques M Oculomotor III Ophthalmic (FH), Maxillary (cheek) Mandible (chin) S Trigeminal V Lateral rectus muscle M Abducens VI Taste to posterior tongue S Vagus X Tongue M Hypoglossal XII Trapezius & Sternocleido. Muscles M Accessory XI Hearing balance S Acoustic VIII Superior Obliques M Trochlear IV Tongue S Facial VII Posterior pharynx, taste to anterior tongue S Glossopharyn- geal IX Smell S Olfactory I Innervation F Name CN

21. Intracranial Volume 80% Brain Matter 10% Blood 10% CSF

22. Intracranial Volume Volume is Fixed at 100% If more of one thing is added, then something else must go. This is called auto regulation Monroe-Kellie Doctrine

23. Cerebral Perfusion Pressure Pressure within cranium (ICP) resists blood flow and good perfusion to the CNS Pressure usually less than 10 mmHg Mean Arterial Pressure (MAP) Must be at least 50 mmHg to ensure adequate perfusion MAP = DBP + 1/3 Pulse Pressure Cerebral Perfusion Pressure (CPP) Pressure moving blood through the cranium CPP = MAP - ICP

24. Calculating MAP Calculating CPP

25. Cerebral Perfusion Pressure Autoregulation Changes in ICP result in compensation Increased ICP = Increased BP This causes ICP to rise higher and BP to rise Brain injury and death become imminent Expanding mass inside cranial vault Displaces CSF If pressure increases, brain tissue is displaced

26. Intracranial Perfusion Compensating for Pressure Compress venous blood vessels Reduction in free CSF Pushed into spinal cord Decompensating for Pressure Increase in ICP Rise in systemic BP to perfuse brain Further increase of ICP Dangerous cycle ICP BP

27. Intracranial Pressure Role of Carbon Dioxide Increase of CO 2 in CSF Cerebral Vasodilation Encourage blood flow Reduce hypercarbia Reduce hypoxia Contributes to  ICP Causes classic Hyperventilation & Hypertension Reduced levels of CO 2 in CSF Cerebral vasoconstriction Results in cerebral anoxia

28. Factors Affecting ICP Vasculature Constriction Cerebral Edema Systolic Blood Pressure Low BP = Poor Cerebral Perfusion High BP = Increased ICP Carbon Dioxide Reduced respiratory efficiency

29. Increased pressure Compresses brain tissue Against & around Falx Cerebri Tentorium Cerebelli Herniates brainstem Compromises blood supply Signs & Symptoms Upper Brainstem Vomiting Altered mental status Pupillary dilation Medulla Oblongata Respiratory Cardiovascular Blood Pressure disturbances Pressure & Structural Displacement

30. Brain shift and herniation

31. Mechanism of Injury Blunt Injury Motor vehicle collisions Assaults Falls Penetrating Injury Gunshot wounds Stabbing Explosions Head Injury

32. Scalp Injury Contusions Lacerations Avulsions Significant Hemorrhage

33. Maxillo-facial Trauma Causes - MVA, home accidents, athletic injuries, animal bites, violence, industrial accidents Soft tissue - lacerations, abrasions, avulsions vascular area supplied by internal and external carotids Management Seldom life-threatening unless in the airway consider spinal precautions have suction available and in control of conscious patients control bleeding

34. Facial Fractures Fracture to the mandible, maxilla, nasal bones, zygoma & rarely the frontal bone S/S - pain, swelling, malocclusion, deep lacerations, limited ocular movement, asymmetry, crepitus, deviated nasal septum, bleeding from orifice Mandibular fracture- malocclusion, numbness, inability to open or close the mouth, excessive salivation Anterior dislocation extensive dental work, yawning Condylar heads move forward and muscles spasm

35. LeForte Fractures

36. Description of LeForte Fracture LeForte I - Maxillary fracture with “free-floating” maxilla LeForte II - Maxilla, zygoma, floor of orbit and nose LeForte III - Lower 2/3 of the face

37. Signs and Symptoms Takes incredible forces especially to sustain a LeForte II or III Edema, unstable maxilla, “donkey face” lengthening, epistaxis, numb upper teeth, nasal flattening, CSF rhinorrhea (cribriform plate fracture) II and II associated with orbital fractures risk of serious airway compromise from bleeding and edema contraindication to nasogastric tube or nasotracheal intubation

38. Linear Skull Fracture About 70% of the skull fractures May occur without any overlying scalp laceration Across temporal-parietal sutures, midline, or occiput may lead to epidural bleed from vascular involvement of underlying structures

39. Basilar Skull Fracture Associated with major trauma Does not always show on x-ray Clinically diagnosed with following Ecchymosis over the mastoid (temporal bone) Ecchymosis over one or both orbits (sphenoid sinus fracture) blood behind the tympanic membrane (temporal bone) CSF leakage Complications - infection, cranial nerve damage, hemorrhage from major artery

40. Depressed Skull Fracture Most common to parietal and frontal area high velocity small objects cause it 30% associated with cerebral hematoma or contusion Dural laceration likely Definitive treatment includes elevation of depressed fragments

41. Open Vault Fracture High mortality due to forces required to cause injury Direct contact between laceration and cerebral substance Usually involves multiple system trauma

42. Brain Injury As defined by the National Head Injury Foundation “a traumatic insult to the brain capable of producing physical, intellectual, emotional, social and vocational changes.” Classification Direct Primary injury caused by forces of trauma Indirect Secondary injury caused by factors resulting from the primary injury

43. grading

44. Secondary injuries all deleterious post-traumatic events other than the actual mechanical brain lesion (focal or diffuse) sustained at impact Could be systemic or intracranial Importance is - Patient outcome - possible intervention

45. Direct Brain Injury Categories Focal Occur at a specific location in brain Differentials Cerebral Contusion Intracranial Hemorrhage Epidural hematoma Subdural hematoma Intracerebral Hemorrhage Diffuse Concussion Moderate Diffuse Axonal Injury Severe Diffuse Axonal Injury

46. Concussion No structural damage - mild to moderate impacts reticular activating system or both cortices temporarily disturbed, resulting in LOC or altered consciousness may be followed by dizziness, drowsiness, confusion, retrograde amnesia vomiting, combativeness, transient visual disturbances changes to vital signs are rare but possible

47. Cerebral Contusion Bruising of brain in area of cortex or deeper within frontal, temporal or occipital lobes greater neuro deficits than concussion due to structural change from bruising Seizures, hemiparesis, aphasia, personality changes, LOC or coma of hours to days 75% of patients dying from head injuries have associated cerebral contusions

48. Cerebral Contusions………. Coup and contra coup injury may cause disruption of blood vessels within the pia mater as well as direct damage to the brain substance Contracoup is most commonly caused by deceleration of the head (fall, MVA) Usually heal without surgical intervention/ Patients improve over time. Most important complication is increased ICP

49. Diffuse axonal injury Comatose after the injury with prolonged coma or severe disability after wards Shearing forces on nerve fibers in the white matter Accounts for 35 % of the death from head injuries Shear and tensile stresses within the brain as a consequence of inertial loading to the head Similar mechanism to concussion but the level of inertial loading is low in concussion.

50. Pathologically, the classic triad of DAI presents as gross focal lesions (typically hemorrhagic) in the corpus callosum and dorsolateral quadrant of the midbrain and pons , along with microscopic axonal retraction balls of Cajal throughout the subcortical white matter Can also present without macroscopic findings where CT could be normal Commonly due to MVA’s Less incidence of increased ICP’s except when associated with focal injuries

51. Brain Hemorrhage Classified by location epidural subdural subarachnoid parenchymal intraventricular

52. Epidural Bleed Between Cranium and dura mater rapidly developing lesion from laceration or tear to meningeal artery Associated with linear or depressed skull fracture of the temporal bones 30% patients have transient LOC with lucid interval of 6-18 hours

53. Epidural continued Initial LOC is caused by concussion, followed by awakening and then loss of consciousness from pressure of blood clot 50% lose consciousness and never wake up due to rapid bleeding rate Lucid period may only be accompanied by headache followed by nausea, vomiting, contralateral hemiparesis, altering states of consciousness, coma and death Common in low velocity blows 15-20% mortality

54. Subdural Hematoma Blood between the dura and brain surface blood from veins that bridge the subdural space associated with lacerations or contusions to brain and skull fracture

55. Subdural Continued 50-80% mortality in acute injury (symptoms within 24 hours) 25% mortality in subacute injury (2-10 days) 20% mortality in chronic injury (> 2 weeks) Signs and Symptoms similar to epidural Absence of “lucid interval” increased risk factors are: advanced age, clotting disorders, alcohol abuse, cortical atrophy May appear like a stroke! Rule out trauma.

56. Subarachnoid Bleed Most common cause is trauma Associated with congenital causes marfan’s syndrome coarctation of the aorta polycystic kidney disease sickle cell disease Mortality - 10-15% die before reaching the hospital 40% within the first week 50% within 6 months

57. Subarachnoid Bleeding and site of aneurysm bleeding

58. Posttraumatic seizures Immediate Early Late

59. Assessment and Management Airway - assume spinal injury with significant head trauma consider intubation with GCS of less than 8 suction at ready use orogastric instead of nasogastric tube in facial injuries ventilate for adequate gas exchange and to decrease ICP.

60. Circulation Control bleeding apply monitor (not highest priority) head injury does not produce hypovolemic shock, look for another cause if patient is hypotensive

61. Neurological Assessment Interview for LOC on person, place, time, events, last clear recall do this early in conscious patients and be patient! Get a history while you can. Check motor function (gross and fine) check for drift Check pupils Check for extraocular movement (nystagmus and bobbing)

62. Neurological….. General examination -visual exam of the cranium -auscultation over the carotids -signs of trauma to the spine -any observed seizure Level of consciousness (GCS) Motor examination: noxious stimulus Reflexes: DTR, plantar reflex

63. Glasgow Coma Scale

64. Clinical risk categorization Low risk for IC injury Moderate risk for IC injury High risk for IC injury Asymptomatic History of change in consciousness Depressed level of consciousness not due to other causes Head ache Progressive HA FND dizziness Alchol,or drug intoxication Penetrating injury Scalp hematomas ,laceration, abrasions Post traumatic seizures Post traumatic amnesia Significant depressed skull fracture Unreliable or inadequate hx Decreasing level of consciousness Significant subgaleal hematoma All others not fitting to the other categories Age <2 yrs,child abuse Vomiting, signs of BSF Multiple trauma

65. Recommended managements 1 .Low risk – observation at home with written head injury instructions 2.Moderate risk patients -CT scan – normal observation at home if initial GCS is ≥ 14,pt now neurologically intact, - abnormal admit and manage - CT unavailable – observation in hospital -SXR – helps only if positive 3.High risk pts – CT scan and admission

66. Radiographic evaluations 1 .CT scans A .Indications for initial CT -presence of any moderate /high risk for ICI -GCS ≤ 14 - any deterioration in neuro status B.Indications for follow up CT -Severe HI -stable b/n day 3-5(some say in 24hrs) -again on day 10 -14 -mild to moderate HI – Abnormal initial CT repeat before discharge - if normal initial CT – no follow up CT - for all if neurological deterioration(loss of 2 or more GCS points, new deficits ) -urgent repeat CT

67. 2.Skull x-rays -presence of fracture – increases the probability of a surgical intracranial injury 20 and 400 fold in comatose and conscious pts respectively -75 % of pts with normal SXR had IC lesions on CT -affect management in only 0.4-2 % of cases -SXR may be helpful in -moderate risk pts -in the absence of CT scans it can show ; - pineal shift -pneumocephalus - air-fluid levels in the air sinuses -skull fractures 3.MRI - Brain stem injuries, DAI

68. Other Investigations CBC count including platelet count Blood chemistries and electrolyte Prothrombin time (PT) or international normalized ratio (INR) Activated partial thromboplastin time ( aPTT )

69. Management outline Airway management Breathing Circulation: fluid management, prevention of DVT Head elevation Analgesics Sedatives Paralytics Ulcer prophylaxis

70. Management……….. Hyperosmolar therapy Diuretics Seizure prophylaxis Antibiotics Steroids ???? Therapeutic hypothermia Barbiturate coma CSF drainage Decompressive craniectomy

71. Management…… Surgical management Hematoma Depressed skull fracture Basal skull fracture Refractory raised ICP