MANAGEMENT_OF_HEAD_INJURIES-1.........ppt

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1. MANAGEMENT OF HEAD MANAGEMENT OF HEAD
INJURIESINJURIES
KEVIN HENSHAWKEVIN HENSHAW
BSc.(Hons.) Cert.Ed RODPBSc.(Hons.) Cert.Ed RODP

2. OBJECTIVESOBJECTIVES
•TO BE AWARE OF THE PROBLEMS TO BE AWARE OF THE PROBLEMS
ASSOCIATED WITH DEALING WITH ASSOCIATED WITH DEALING WITH
PATIENTS WITH AN ACUTE HEAD INJURY PATIENTS WITH AN ACUTE HEAD INJURY
WITHIN THE PERI-OPERATIVE AREAWITHIN THE PERI-OPERATIVE AREA
•TO HELP MAINTAIN HOMEOSTASIS IN TO HELP MAINTAIN HOMEOSTASIS IN
THE HEAD INJURED PATIENTTHE HEAD INJURED PATIENT

3. BACKGROUNDBACKGROUND
•Approximately 1 Million patients annuallyApproximately 1 Million patients annually
•50% of trauma-related deaths from 50% of trauma-related deaths from
severe head injury severe head injury
•1% OF ALL UK DEATHS1% OF ALL UK DEATHS
•85% OF ALL SEVERELY HEAD INJURED 85% OF ALL SEVERELY HEAD INJURED
PATIENTS REMAIN DISABLED AFTER 1yrPATIENTS REMAIN DISABLED AFTER 1yr
•ONLY 15% RETURN TO WORK AFTER 5yrsONLY 15% RETURN TO WORK AFTER 5yrs

4. AssessmentAssessment
•Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)
•GCS 13-15 (Mild) GCS 13-15 (Mild) 80%80%
•GCS 9-12 (Moderate) GCS 9-12 (Moderate) 10%10%
•GCS 3-8 (Severe) GCS 3-8 (Severe) 10%10%

5. Glasgow Coma ScoreGlasgow Coma Score
The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best
Eye Response, Best Verbal Response, Best Motor Response, as given below : Eye Response, Best Verbal Response, Best Motor Response, as given below :
Best Eye Response. (4) Best Eye Response. (4)
No eye opening. No eye opening.
Eye opening to pain. Eye opening to pain.
Eye opening to verbal command. Eye opening to verbal command.
Eyes open spontaneously.Eyes open spontaneously.
Best Verbal Response. (5) Best Verbal Response. (5)
No verbal response No verbal response
Incomprehensible sounds. Incomprehensible sounds.
Inappropriate words. Inappropriate words.
Confused Confused
Orientated Orientated
  
Best Motor Response. (6)Best Motor Response. (6)
No motor response. No motor response.
Extension to pain. Extension to pain.
Flexion to pain. Flexion to pain.
Withdrawal from pain. Withdrawal from pain.
Localising pain. Localising pain.
Obeys Commands.Obeys Commands.
•The Glasgow Coma Scale (GCS) was developed by Teasdale and The Glasgow Coma Scale (GCS) was developed by Teasdale and
Jennett in 1974 Jennett in 1974

6. PATHOLOGYPATHOLOGY
•SCALP SCALP
•lacerations, contusions or abrasionslacerations, contusions or abrasions
•CRANIUM CRANIUM
•simple or compunded,depressed or simple or compunded,depressed or
planar, base or vaultplanar, base or vault

7. PATHOLOGYPATHOLOGY
•UNDERLYING BRAINUNDERLYING BRAIN
•Primary (result of impact)Primary (result of impact)
•Secondary (result of non homeostatic Secondary (result of non homeostatic
factors)factors)

8. PRIMARYPRIMARY
•Intra-cranial haematoma Intra-cranial haematoma
(intracerebral,extradural or subdural)(intracerebral,extradural or subdural)
•Contusion (coup or contre-coup to Contusion (coup or contre-coup to
impact site)impact site)
•Diffuse axonal (result of mechanical Diffuse axonal (result of mechanical
shearing following deceleration)shearing following deceleration)

9. NORMAL BRAIN IMAGENORMAL BRAIN IMAGE

10. EXTRA DURAL HAEMATOMAEXTRA DURAL HAEMATOMA
•Extradural haemorrhageExtradural haemorrhage
–Results from rupture of Results from rupture of
one of the meningeal one of the meningeal
arteries that run between arteries that run between
the dura and the skull.the dura and the skull.
–The middle meningeal The middle meningeal
artery is most commonly artery is most commonly
affected.affected.
–Usual cause is a skull Usual cause is a skull
fracturefracture

11. ACUTE SUB DURAL HAEMATOMAACUTE SUB DURAL HAEMATOMA
Subdural haemorrhageSubdural haemorrhage
More common than More common than
extradural haemorrageextradural haemorrage
Associated with sudden Associated with sudden
jarring or rotation of the jarring or rotation of the
headhead
Shears and tears the small Shears and tears the small
veins which bridge the gap veins which bridge the gap
between the dura and between the dura and
cortical surface of the braincortical surface of the brain

12. TRAUMATRAUMA

13. TRAUMATRAUMA

14. TRAUMATRAUMA

15. SECONDARYSECONDARY
•RESULT OF:RESULT OF:
•IschaemiaIschaemia
•Cerebral oedemaCerebral oedema
•InfectionInfection
•Tonsillar or tentorial herniationTonsillar or tentorial herniation
•ALL EXACERBATE ORIGINAL HEAD ALL EXACERBATE ORIGINAL HEAD
INJURY!!!INJURY!!!

16. INTRA CEREBRAL ABCESSINTRA CEREBRAL ABCESS

17. •NORMAL AUTOREGULATION OF CBF IS NORMAL AUTOREGULATION OF CBF IS
LOST IN SEVERE HEAD INJURY MAKING LOST IN SEVERE HEAD INJURY MAKING
THE INJURED BRAIN MORE THE INJURED BRAIN MORE
SUSCEPTIBLE TO :SUSCEPTIBLE TO :
•HYPO-OR HYPER VOLAEMIAHYPO-OR HYPER VOLAEMIA
•HYPOXIAHYPOXIA
•HYPERCAPNEAHYPERCAPNEA

18. INTRACRANIAL PRESSUREINTRACRANIAL PRESSURE
•MONRO-KELLIE DOCTRINEMONRO-KELLIE DOCTRINE
•‘‘CRANIUM IS CLOSED BOX’CRANIUM IS CLOSED BOX’
•‘‘Contents are incompressible, increase Contents are incompressible, increase
in one constituent or an expanding in one constituent or an expanding
mass within the skull results in an mass within the skull results in an
increase in intracranial pressure’ increase in intracranial pressure’

19. FACTORS INFLUENCING FACTORS INFLUENCING
OUTCOMEOUTCOME
•NORMOTENSION:NORMOTENSION:
•Single episode of hypotension can have Single episode of hypotension can have
catastrophic effect (systolic <90mm Hg)catastrophic effect (systolic <90mm Hg)
•Initial treatment –fluid resuscitationInitial treatment –fluid resuscitation
•Vasopressors – epinepherineVasopressors – epinepherine
•MAP of 70mm HgMAP of 70mm Hg

20. FACTORS INFLUENCING FACTORS INFLUENCING
OUTCOMEOUTCOME
•NORMOXIA:NORMOXIA:
•Hypoxemia (Spo2<90%) decreases Hypoxemia (Spo2<90%) decreases
prognosis possibly by four fold increase prognosis possibly by four fold increase
in mortality (Spo2<60%)in mortality (Spo2<60%)
•O2 maintenance needs to be balanced O2 maintenance needs to be balanced
against any other factors egg PEEP & against any other factors egg PEEP &
chest traumachest trauma

21. FACTORS INFLUENCING FACTORS INFLUENCING
OUTCOMEOUTCOME
•NORMOCAPNIA:NORMOCAPNIA:
•Hyperventilation (PaCO2 <25 mm Hg) should Hyperventilation (PaCO2 <25 mm Hg) should
be avoided for first 24h after Head Injury.be avoided for first 24h after Head Injury.
•Hyperventilation results in vasoconstriction, Hyperventilation results in vasoconstriction,
reduced CBF.reduced CBF.
•First 24h CBF reduced by 50% First 24h CBF reduced by 50%
hyperventilation may result in further hyperventilation may result in further
cerebral ischemiacerebral ischemia

22. FACTORS INFLUENCING FACTORS INFLUENCING
OUTCOMEOUTCOME
•NORMOTHERMIA:NORMOTHERMIA:
•Increased body and brain temp’ Increased body and brain temp’
increases CBFincreases CBF
•Cerebral metabolism and O2 utilisationCerebral metabolism and O2 utilisation
•Increase in ICPIncrease in ICP

23. TRAUMATRAUMA
•REMEMBER:REMEMBER:
•AIRWAYAIRWAY
•BREATHING BREATHING
•CIRCULATIONCIRCULATION
•CERVICAL SPINE (until patient is awake CERVICAL SPINE (until patient is awake
treat as potentially unstable)treat as potentially unstable)

24. QUESTIONSQUESTIONS