4head Injury
Transcript of 4head Injury
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HEAD INJURY
ByDr. Keiza .N.
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DEFINITION
Trauma to the head.
Neurological disruption.
Variable presentation.
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INCIDENCE
In the USA, 500,000 new cases
10% die before hospital.
10% are severe. 10% are moderate.
80% are mild.
Many deaths and comorbidities can bereduced through prompt referral .
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ANATOMY
Scalp- five layers: skin, connective tissue,aponeurosis ,loose areolar tissue andpericranium
skull: cranial vault- smooth, some areas thin.pterioncranial base is irregular- anterio and middle
cranial fossa
Meninges: three layers. Dura mater,arachnoidand pia.
Brain specific functions
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ANATOMY(cont)
Cerebrospinal fluid-30ml per hour, from
choroid plexus
Tentorium- supra and infratentorial
compartments .Tentorial incisura edge
closely related to third cranial nerve and
uncus
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PHYSIOLOGY
Intracranial pressure normal 10mmHg or 136mm water.
Above 20mmhg is abnormal
Monroe Kellie doctrine -brain+blood +csf is aconstant. Initial compensation, eventuallyexponential rise.
Cerebral perfusion CPP=MAP-ICP. Perfusion
pressure of
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CLASSIFICATION
Mechanism of injury- blunt or penetrating
Severity of injury-GCS
Morphology of injury- skull orintraparenchymal
Primary or secondary
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SKULL FRACTURE
Linear
Depressed
These could be open or closed
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PATHOLOGY
Primary brain injury- at impact
Secondary-complications-:
-haematoma
-brain swelling
-hypoxia
-infection
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INTRACRANIAL BLEED
Epidural
Subdural
Subarachnoid intracerebral
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MANAGEMENT
History
Physical examination
Radiological investigationsskull radiograph,
cat scan,
MRI
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PRIMARY SURVEY
A.-ABCDE
B-Immobilize and stabilize the cervical
spine
C-Perform a brief neurological exam
1.pupillary response.
2.GCScore determination.
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SECONDARY SURVEY
A-.Inspect the entire head. Remove dressings ,look forlacerations or csf
B-Palpate for fractures including the wounds
C-Inspect all scalp lacerations-look out for
brain,depressed fractures,debris or csf D-Minineurological examination--GCS -BEST
- -Eye
-Motor- - Verbal
Pupillary responseE-Examine cervical spine
F-Determine the extend of the injury
G-Regular reassessment
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INVESTIGATIONS
A-Radiographs
B-CT SCAN
-scalp
-bone-subdural/epidural space
-surface sulci
-brain parenchyma
-ventricles-midline structures and basal cisterns
-posterior fossa
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SPECIFIC MANAGEMENT
MILD HEAD INJURY-GCS 14 or 15
-Approx 80% of pts in A &E have mild HI-majority recover fully
-3% deteriorate suddenly-ideally, all with long period of loc shouldhave a CT scan-ideally admit for observation for 24 hours-advise to come back in case of anywarning signs
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MODERATE HEAD INJURY
GCS 9-13
Approx 10 % of patients in A&E departm
May have focal signs. 10-20% may deteriorate
Up to 40% have abnormal scans
Admit even if CTscan is normal
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SEVERE HEAD INJURY
GCS 3-8
Cannot follow commands
Up to 30% are hypoxaemic-
13% hypotensive
12% anaemic
Combination of hypoxia and hypotensionleads up to 75% mortality.
Admit all and protect airway from early
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HAEMATOMA-SUBDURAL
CTscan confirmation
Indications for surgery:
-focal neurological signs
-altered loc
-features of raised ICP
Burr holes or craniotomy
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EPIDURAL HAEMATOMA
CT confirmation
Usually ruptured middle meningeal artery
occasionally dural venous sinus rupture
Indication for surgery focal signs or
raised ICP
craniotomy
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INTRACEREBRAL HAEMATOMA
Indication for surgery -raised ICP
Safe access of the haematoma is very
important
Craniotomy
Deficits may persist
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LINEAR FRACTURE
Simple -no indication for surgery
Compound- theatre for surgical
debridement and stitching
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DEPRESSED SKULL FRACTURE
Closed elevation in case it is significant
Compond- Theatre for surgical
debridement and elevetion
Antibiotic cover
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RAISED ICP
Ventillatory support
Mannitol
lasix
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Extradural haematoma
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Subdural haematoma
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Bilateral subdural haematoma
acute on chronic
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Bilateral subdural haematoma MRI
findings
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Brain oedema
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Post-craniotomy extradural
haematoma
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Post-craniotomy extradural
haematoma
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Intracerebral haematoma with
marked brain swelling
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Intracerebral haematoma