management of head trauma.ppt for medical students

Management of brain injury

1. Head Injury-Clinical
Manifestations,Diagnosisand
Management
DrkamkarAeinfar
Neurosurgery
department of tehran
university

3. Classification
Direct
Primary injury caused by forces
of trauma
Indirect
Secondary injury caused by
factors resulting from the primary
injury

4. Direct Brain Injury Types
Coup
Injury at site of
impact
Contrecoup
Injury on opposite
side from impact

5. Brain Injury
Indirect brain injury
•Results from hypoxia
or decreased perfusion
•Response to primary injury
•Develops over hours
Management
•Good prehospital care can help prevent
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6. Direct Brain Injury Categories
Focal
Occur at a specific location in brain
Differentials
Cerebral Contusion
Intracranial Hemorrhage
Epidural hematoma
Subdural hematoma
Intracerebral Hemorrhage
Subarachnoid hemorrhage
Diffuse
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury

7. Focal Brain Injury
Intracranial Hemorrhage
Epidural Hematoma
Bleeding between dura
mater and skull
Involves arteries
Middle meningeal artery
most common
Rapid bleeding &
reduction of oxygen to
tissues
Herniates brain toward
foramen magnum

8. Intracranial Hemorrhage
Acute epidural hematoma
•Arterial bleed
Temporal fracture common
Onset: minutes to hours
•Level of consciousness
Initial loss of consciousness
“Lucid interval” follows
•Associated symptoms
Ipsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness,
contralateral paralysis, death
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9. Focal Brain Injury
Intracranial Hemorrhage
Subdural Hematoma
Bleeding within meninges
Beneath dura mater & within
subarachnoid space
Above pia mater
Slow bleeding
Superior sagital sinus
Signs progress over several days
Slow deterioration of mentation

10. Intracranial Hemorrhage
Acute subdural hematoma
•Venous bleed
Onset: hours to days
•Level of consciousness
Fluctuations
•Associated symptoms
Headache
Focal neurologic signs
•High-risk
Alcoholics, elderly, taking anticoagulants
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11. Intracranial Hemorrhage
Intracerebral hemorrhage
•Arterial or venous
Surgery is often not helpful
•Level of consciousness
Alterations common
•Associated symptoms
Varies with region and degree
Pattern similar to stroke
Headache and vomiting
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12. CTfindings
Epidural Hematoma Subdural Hematoma
Fig.55-15

13. CTfindings
Subarachnoidhemorrhage Intracerebral hematoma
Fig.55-15

14. Diffuse Brain Injury
Due to stretching forces placed on individual nerve cells
Pathology distributed throughout brain
Types
Concussion
Moderate Diffuse Axonal Injury
Severe Diffuse Axonal Injury

15. Brain Anatomy
Intracranial volume
•Brain
•CSF
•Blood vessel volume
Dilatation with high pCO
2
Constriction with low pCO
2
Slight effect on volume
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16. Intracranial Perfusion
Cranial volume fixed
80% = Cerebrum, cerebellum & brainstem
12% = Blood vessels & blood
8% = CSF
Increase in size of one component diminishes size of another
Inability to adjust = increased ICP

17. Head Trauma -17
Decreased level of consciousness
is an early indicator of
brain injury or rising ICP.

18. Glasgow Coma Scale
Suspect severe brain injury GCS <9
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*Decorticate posturing to pain
**Decerebrate posturing to pain

19. Extremity Posturing
Decorticate
•Arms flexed
and legs extended
Decerebrate
•Arms extended
and legs extended
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20. Head Trauma -20
Early efforts
to maintain brain perfusion
can be life-saving.

21. Management
1)Supportive Measures:
•Endotrachealintubationfor patients with decreased levelof
consciousness and poor airwayprotection.
•Cautiouslylower bloodpressure to aMAPlessthan 130 mm
Hg, butavoidexcessive hypotension.
[10]
•Rapidlystabilize vitalsigns, and simultaneouslyacquire
emergentCT scan.
•Maintaineuvolemia,usingnormotonicrather thanhypotonic
fluids, to maintain brain perfusion without exacerbating brain
edema
•Avoidhyperthermia.
•Facilitate transfer totheoperatingroomor ICU.

22. Management
2)Decrease cerebral edema:
•Modestpassive hyperventilation to reduce PaCO2
•Mannitol, 0.5-1.0 gm/kg slowiv push
•Furosemide 5-20 mg iv
•Elevate head20-30 degrees, avoidany neck vein
compression
•Sedate and paralyze if necessary with morphine and
vecuronium (struggling,coughing etc will elevate
intracranialpressure)

23. Management
3)SurgicalEvacuationofhematoma:
•Nosurgicalintervention if collection<10ml
Indication of surgical
•The GCSscore decreasesby2 or more pointsbetween the
timeofinjuryandhospitalevaluation
•The patientpresentswith fixedand dilated pupils
•The intracranialpressure (ICP)exceeds20 mm Hg
Exception :
In Subdural hematoma with GCS=15-hematoma >10mm ,or
>5mm midline shift ----requires Surgical decompression
SAH: whn a cerebral aneurysm is identified on
angiography, clipping and coiling is done to prevent re-bleed
decompression:

24. Management
SugicalDecompressioncontd..
Types:
•Burr-hole
•Craniotomy-bone flapis temporarilyremovedfrom
the skullto access the brain
•Craniectomy–inwhich the skull flapis not immediately
replaced, allowing the brain to swell, thus reducing
intracranial pressure
•Cranioplasty-surgical repair of a defectordeformity of
a skull.

25. Management
4)Medical therapy:
•Antihypertensives-reduce bloodpressure to preventexacerbation
of intracerebral hemorrhage in hypertensive encephalopathy. Eg
Nicardipine, labetolol; CCB help relieve vasospasm in SAH and
decrease further damage
•Diuretics -Mannitol,CAI
•Anticonvulsants –reduce frequencyofseizures andprophylaxisof
seizures eg: Fosphenytoin
•Antipyretics-to Rxfeverandpain reliefeg:Acetaminophene
•Antidote-
VitK/FFP for warfarin overdose;
protamine for heparin overdose
•Antacids-prophylaxis for Cushing’s gastric ulcer eg:Famotidin
•Glucorticoids mayhelp reduce the headand neck ache causedby
the irritativeeffect ofthe subarachnoid blood.

27. 27Head Trauma -

28. Remember…
…it’s okay if you do not
diagnose the patient’s problem.
It’s not okay if you fail to take
care of what you are trained to
take care of.

29. Thank you