Head trauma, Types of head trauma and intracranial bleed.pptx

Head Injury

1. General Surgery Head Trauma E. E. Okon MRCS

2. Case 1 A 22-year-old man was walking past a construction site when a brick fell off the scaffold and struck him in the head. Witnesses noted that the patient was unconscious immediately after the incident and did not regain consciousness for approximately 10 minutes. The paramedics placed the patient in cervical spine precautions and brought him to the emergency department. During the primary survey at the emergency department, the patient has apparently normal air exchange, a respiratory rate of 18 breaths/min, blood pressure of 138/78 mm Hg, and a pulse of 80 beats/min. The patient does not open his eyes in response to voice commands but has eye opening in response to painful stimuli. He withdraws from painful stimuli. His only verbal responses are incomprehensible sounds. The secondary survey demonstrates a 3-cm scalp laceration and a contusion over the right temporal region. The right pupil is dilated 6 mm and sluggishly reactive to light; the left pupil is 4 mm in diameter and reacts normally to light. No blood is visualized behind the tympanic membranes. The results from an examination of the truncal region and extremities are within normal limits. What is the most likely diagnosis? What should be your next step?

3. Head Injury 1. Assessment 2. Resuscitation 3. Establishing the diagnosis 4. Ensuring that metabolic needs of the brain are met 5. Preventing secondary brain damage

4. Classification of Head Injury Mechanism Blunt Penetrating – requires surgical intervention and repair Severity* (Mena, J. H., Sanchez, A. I., Rubiano, A. M., Peitzman, A. B., Sperry, J. L., Gutierrez, M. I., & Puyana, J. C. (2011). Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. The Journal of trauma, 71(5), 1185–1193. https://doi.org/10.1097/TA.0b013e31823321f8) Mild (14-15) Moderate (8-14) Severe (3-8) Motor is best prognostic indicator of overall neurologic outcome

5. Classification of Head Injury Pathology of Injury Focal/diffuse Primary/Secondary Skull/Intracranial lesions

6. Who should get a CT Scan Moderate & Severe TBI Closed TBI with GCS < 14 Post-traumatic seizure LOC or Amnesia Skull fracture or contusion Elderly patients or those patients on antiplatelet agents or anticoagulation History of alcohol intoxication Age more than 60 years Signs of Basal Skull # The presence of lateralizing findings

7. Mechanism of Brain damage post-TBI Hypoxia/ischaemia Contusion Coutre coup injuries Diffuse axonal Injury Injury to axonal tracts Mild – Coma lasting 6-12 hours – Concussion Moderate – Coma lasting >24hrs (No brainstem dysfunction) – M.R 20% Severe – Coma lasting > 24hrs (With brainstem dysfunction) – M.R 50%

8. Intracranial haemorrhage Extradural haematoma - Injury to the temporal or parietal bone Rupture of middle meningeal artery Children and young adults Trauma, Unconsciousness, Lucid Interval, gradual lapsing into coma, Fixed dilated pupil, Contralateral hemiparesis with decerebrate posture. CT – Biconvex, lens shaped hematoma Acute subdural haematoma Rupture of a bridging vein CT – Semilunar, crescent-shaped hematoma Poorer prognosis Chronic Subdural hematoma Elderly and alcoholics Tearing venous sinuses

9. Decerebrate Posturing

10. Intracranial pressure Normal ICP = 10 mmHg Abnormal ICP >20 mmHg Effects Rising ICP causes Cushing’s response Respiratory rate decreases Heart rate decreases Systolic BP increases Pulse pressure increases

11. Management of raised ICP Non-surgical management Sedate and intubate Nurse the patient with tilted head up (aids venous drainage) Maintain normal PCO2 (approximately 3.5–4.0 kPa) • Establish monitoring with an ICP bolt and transducer Aim to maintain CPP at 60–70 mmHg by: • Optimal fluid management • Judicious use of inotropes

12. Aim to maintain ICP at 10 mmHg by: • Mannitol (0.5 g/kg) (usually 100–200 ml 20% mannitol given rapidly may result in a transient mild reduction in ICP • Hyperventilation to PCO2 4.5kPa • Thiopental infusion (15 mg/kg) • Hypothermia (controversial as to whether ‘cool’ to only normoxia or lower) Emergency burr holes or craniotomy

13. Neck Trauma