01. Brain Injury Management_compress

7/30/2019 01. Brain Injury Management_compress

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BRAIN INJURY MANAGEMENT

KHAMIM THOHARI

NEUROSURGEON

MARDI WALUYO GENERAL HOSPITAL

BLITAR EAST JAVA INDONESIA


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ACCIDENT

(SPOT OF ACCIDENT)

BRAIN SCHOCK :

(Secondsminutes)

* No pain reaction

* Apnea

* Bilateral pupil dilatation,negative light + corneal reflex

* Poll is not clear predictable / papable

A1 B1 C


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DEATH ON ARRIVAL

* 17.5% 20% : Before admitted in hospital

* Resuscitation : on the spot : - A , B , C

- Transportation

* Sending to the nearest hospital who has intensive care unit

* Sending to the hospital who has department of neurosurgical

( neurosurgeon and equiptment )


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Cases I : Spatula in the head

Dont extraction curve of the end spatula


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BRAIN INJURY

Continuing process

Unpreventable process

+ Ery throcyte

+ Neurotransmitters

(Spasmogen agents)

+ Inflammatory reaction

+ Acidosis

+ Opioid Endogen

+ Free radicals+ Hormonal

PBI

SBI

Edema cytotoxic

Preventalbe process

Resuscitation Recover

Good

Disturb of A1 B1 C

Hypoxia

Edema cytotoxic

Bad

Reperfusion injury

BBB Disturb

Edema Vasogenic


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OBSERVATION

1. GCS 7. Restlessness

2. Neurologic Sign 8. Seizures

3. Vital Sign : BP, Pulse 9. Urinary

4. Position 10. Skin Care

5. Fluid 11. ICP Monitoring6. Temperature 12. Drug / Medicine

MANAGEMENT Brain Injury

Severe BI

CONSERVATIVE OPERATIVE

Resucitation ABC

Evaluation of GCS

Moderat BIMild BI

Observation

2 hours in EM Insertion ofNG tube, DC IntubationInsertion of NG tube, DC

Dx : CT Scan


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Cases II : * Open fracture on the skull

* Dont remove bone fragment

* The first aid : TRACHEOSTOMY


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MANAGEMENT

1. Head positioning

The tongue drops : losses the muscle strength The head and the body are placed aside

2. A : Airway

Clearance of respiratory tract

3. B : Breathing Massage on the chest

Oxygenation is given

Mouth breathing artificial respiration

4. C : Circulation Signs : + Pale

+ Decrease of pulse rate

+ Arterial pulse unpalpable

Tx : * Stop bleeding

* Infusion


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PRIMARY SURVEY

HYPOXEMIA

HYPEROXEMIA

PAO2 80 120

PACO2 25 35PREVENT

A

B

BPC

Systole : 100 140 mmHg

Diastole : 70 90 mmHg

Hypertension

Hypotension

Shock

Anemia

UrgencyImmediately

Treated


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Skull X Ray Head CT Scan Head MRI Cervical X Ray

IMAGING :


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Skull X RAY INDICATIONS

* Open fracture

* Deformity* Stab wound

* Corpus alienum

* Scraped wound


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Cases III : Klep gun in the eye + skull


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Cases IV : Stick wood in the skull


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Cases V : Bullet in the skull


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CERVICAL SPINE X RAY INDICATIONS

* Scraped wound on the neck

* Neck pain* Traumatic mechanism ( wisplash injury )

* Cervical signs : tetra plegia / paralytis

* Unconscious patients


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CT SCAN INDICATIONS

* Seizures

* Continuous cephalgi, vomiting and vertigo with medicine

* Corpus alienum or stab wound

* GCS < 15

* Lateralization ( anisocor / hemiparalysis )

* Decreased of GCS > 1 point

* Cushing response : hypertension + bradicardy

* Brain + multiple organ injury

* Social indication


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OUT PATIENTS CONDITION

* Conscious + good orientation* No neurological deficit

* Decreased of complain

* No fracture

* Social Problems nobody care at home hospital

distance home / village from the hospital

NOTES : Back to the hospital if patient has :

* Seriously complain (severe complain)

* Restlessness

* Decreased of conscious ( GCS )

* Seizures

* Lateralization


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ICU OBSERVATION

* GCS < 8

* GCS 9 15 : with neurological deficit,

cushing respons

* Progresive neurological deficit

* Progresive of complain : cephalgie ,

vertigo and vomiting


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OBSERVATION

PATIENT

ARTIFICIAL RESP.

Cushing Response Neurologic Signs : Pupil, Motoric

WITHOUT

GCS Cushing Response Neurologic Signs

1 OBSERVATION OF CONSCIOUSNESS


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1. OBSERVATION OF CONSCIOUSNESS

based on GCS

1. Recover

2. SBI

15

151515

15FI15

FI

15FI


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Caused by : Intracranial ProcessesExtracranial Process, ex. : Hypoxemia

2. OBSERVATION OF NEUROLOGICAL DEFICIT

NO LATERALIZATION

Pupil : isocoria

Motoric : normal

LATERALIZATION

Anisocoria

Hemi/Tetra Phareses/Pharalyses


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Bradycardia : Pulse < 60/minute

Hypertension

Cephalgia , Vertigo , Vomiting

CUSHING RESPONSE

Cases VI : EDH ( Epidural Hemorrhage )


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Cases VI : EDH ( Epidural Hemorrhage )


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Head Elevation : + 10 30

+ CBF : N

+ ICP : MechanicalNot > 30 : + CBF

+ Mechanical effect ()CSF cant move to spine

space

4. POSITION


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5. FLUID, ELECTROLYTE AND

NUTRITION IMBALANCE

DAY 1 2 : * 2 liters isotonic fluid

* has an electrolyte : osmolar stabilization

DAY 3 : * nasogastric tube :

- no gastric retention (100 cc/day)

- good peristaltic

- no abdominal distension

- no nausea and vomiting

- start low go slow


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SOME FACTORS NEED TO BE CONSIDERED IN FLUID

ADMINISTRATION ARE

1. Extra fluid 10 15% must be given for every increased

1C temperature

2. Urinary production :* diabetes insipidus : 1 ltr negative balance

* progressive urinary production and prolonged urine

production ( > days)vasopression administration

is needed and electrolytes is periodically examined3. Its not recommended to give glucose 5%glucose

rapidly metabolizesolution changes into hypotonic


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* Rectal temperature

* Hyperthermia brain Hypermetabolism

* Causes of hyperthermia

1. Intracranial : Primary

2. extracranial : Secondary

infection

drug reaction

transfusion reaction

* Treatment+ intracranial : without antipyretics + antibiotic

+ increasing of fluid :

> 1 C (+) 10 15% (extra)

6. TEMPERATURE


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Factors : 1. Intracranial : + start to be alert+ ICP : intracranial

2. Extracranial :

Pain : + full bladder, bone fracture

+ uncomfortable feeling due to dirty bed/

clothing

+ patient is tightened

+ hyperthermia+ respiratory disturbance

Treatment : + etiologic factors must be found and treated

+ medical : chlorpromazine : 25 mg

diazepam : 5 10 mg

7. RESTLESSNESS


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* Occurred due to iritative of brain and Ca

* Treatment :

1. Diazepam : 10 40 mg iv during attack

Phenitoin : 3 5 mg Kg/BW/Dose

Phenobarbital : 3 5 mg Kg/BW/Dose

2. In epileptic status : should be more intensively treated

3. Until EEG normal or 2 years seizures free

* Prevent :

- Severe BI

- ICH Traumatic- Edema

- Depressed Fracture

- Foreign Bodies

- Acute Seizures

2+

IC

8. SEIZURES

Cases VII : Severe brain injury complication : brain athropy


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Cases VII : Severe brain injury complication : brain athropy


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Dauer catheter is inserted with the aim

* to monitor urinary production* to calculate the fluid balance

* to keep the bed clean and dry

* to prevent restlessness due to full bladder

9. URINARY : MICTURATION


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* Skin area with continuous pressure decubitus* Dangerous :

- infection sepsis

- serum fluid

hypoalbumin* Treatment

- turning position periodically

- giving soft pillows beneath parts of the body which

are under continuos pressure

10. SKIN CARE

11. ICP MONITORING


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ICP : Monitoring Out Come Prediction Intraventricular Monitoring < 20 mm H2O

CPP : MAP ICPCPP : + 75 mmHg

MAP Slight HypertensionICP Mechanical : Position CSFIC

Medical : Acetazolamic

Mannitol

Corticosteroid


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Ca2+ Blocker Antioxidant Dehydration Agent Nootrophic : Nicholin

Piracetam :

* Rheology

* CBF

12. DRUG MEDICINE

HEMORRHAGE


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HEMORRHAGE

SMALL

HEMORRHAGEBRAIN COMPENSATED : MILD COMPLAIN :

Cephalgi, Vertigo,

Restlessness, Vomiting,Amnesia

LARGE

HEMORRHAGEUNCOMPENSATED : HEAVIER :

* Lateralization

anisocoriahemiparese/paralytic

* Cushing response

hypertension

bradycardia

HERNIATION : * Apnea* Hyperthermi

* Bilateral pupil

mydriasis

* Decerebration

* Cardiac arrest

CURABLE OPERATIVE

REPERFUSION INJURY

REBLEEDING

POST OPERATIVE DECOMPRESSION


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POST OPERATIVE DECOMPRESSION

OPERATIVE

DECOMPRESSION

POSITIVE PRESSURE NEGATIVE PRESSURE

POOLING OF BLOOD

INTRAVASCULAR PRESSURE

EDEMA RUPTURE

HEMORRHAGE


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Teknik operasi drainase ventrikel


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Diffuse Brain Injury

Normal CT Diffuse Injury

Range from mild concussion to severe ischemic

insult


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Intracerebral Hematoma / Contusion

Large Frontal Contusion with Shift


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Subdural Hematoma


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Epidural Hematoma

Temporal Epidural Hematoma

Uncal herniation


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SUMMARY


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1. It is important to observe the changes of consciousness, especially

when the patient is firstly seen, during transportation to / at thehospital

2. 17.5 20% patient expected to die before arriving in the hospital

3. In the hospital : ( recent management)

* primary survey : stabilization : A B C

* diagnostic* definitive treatment

- operative

- conservative

- observation 12 points

4. Goal of brain injury treatment

a. curable

b. to prevent of SBI

c. to minimize invalidity and death

d. the end results of treatment is good outcome

SUMMARY


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THANK YOU

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