Case 27-2019: A 16-Year-Old Girl with Head Trauma during a ...
Head Trauma - Case
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Lamhot Asnir L. Tobing, M.D.
Neurosurgeon
Presentant:
Sardito (2012.061.069)
Deiby P S (2013.061.015)
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Identity
Name : Mr. A Y
Gender : Male
Age : 30 y.o.
Occupation : Construction worker
Religion : Moslem
Address : Gong Bay Date of hospitalization : July 11th2014
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Anamnesis
Chief complaint : loss of consciousness
History of present illness : Patient came with chief complaint of loss of
consciousness approximately for a 30-minute period
after trauma Patient fell from a 5-metre height while he was
working on a building construction around 40minutes before hosptalization.
According to the witnesses, the patients right leg hit
an iron rod before finally fell onto the road (ashpalt)with the left side of the head hitting the road first.
Along the journey to the hospital, the patientreceived no medication at all.
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Meanwhile during in the Emergency Room, the
patient vomited 4 times with the total of +600mL
fluid being discharged containing gastric juice andblood.
Patient also felt pain throughout the body
including severe headache
The patient denied the existence of blood
discharge from the nose and ears
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History of past illness:
History of hypertension denied
History of stroke denied
History of allergy denied
History of Diabetes Melitus denied
History of past trauma denied
History of chronic cough denied
History of regular drug consumption denied
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Habits:
Patient has been smoking cigarette since 15years ago 12 cigars per day
Patient also occasionally counsumed alcoholic
beverages but not on a regular basis and not sure
about the amount consumed Development :
Patient experienced no problem in during
developing stage of life
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Primary Survey
A : good articulation, obstruction (-)
B : RR: 26 tpm
C : BP : 160/100 mmHg; HR : 120 bpm
D : Compos Mentis (GCS 14E3M6V5)
E : Temp : 36,5oC
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Allergy : -
Medication : -
Past Illness : -
Last Meal : unkown
Environment : 5-metre height fell
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Physical examination
General condition : severely ill
Head :
Calvarium : hematoma a/rfrontalis sinistra o
+ 3cm
Face : asymmetrical
Eyes : edema palpebra sinistra
Nose : nasal septal in the middle Mouth : oral mucose wet
Ear : MAE +/+
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Neck :
JVP : not assessable Carotid Artery : +
Thyroid : not palpable
Thorax : Cor : cardiomegaly -; Heart Sound I & II regular;
Murmur -; Gallop -
Pulmo : symmetrical; VBS +/+; Wheezing -/-;
Rales -/-
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Abdomen :
Liver : hepatomegaly
Spleen : splenomegaly
Bladder : not palpable
Extremities :
Warm, CRT
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Neurological examination
Meningeal stimulation
Not assessable
Signs of intracranial pressure increase
Headache +
Blurry vision
Bradycardia
Papiledema
Cranial nerve examination is between
normal limits
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Motoric :
Upper arms : 5555/xxxx
Lower arms : 55/55
Hands : 55/55
Fingers : 5555/5555
Upper legs : xxxx/5555 Lower legs : xx/55
Feet : 55/55
Toes : 55/55
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Physiological reflexes :
Biceps : +/+
Triceps : +/+
Patella : x/+
Achilles : -/-
Pathological reflexes : all are negative Clonus : patella -; feet
Tonus : normotonus, spasticity -; rigidity-
Coordination and cerebelar function : not assessable
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Sensibilities are between normal limits
Autonomic system
Miction : + (catheter)
Defecation : -
Sweating : + above shoulder
Noble function :
Motoric aphasia : -
Sensoric aphasia : -
No signs of regression Peripheral nerve are not palpable
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Lab test - July 12, 2014Parameter Value
HEMATOLOGY
IV Routine
Hemoglobin 14.9
Hematocrit 41
WBC 20.9
Thrombocyte 308
Erythrocyte sedimentation rate 10
DIFFERENTIAL COUNT
Basophils 0
Eosinophils 0
Band neutrophils 0
Segmented neutrophils 83
Lymphocytes 12
Monocytes 5
Bleeding Time 3
Clotting Time 5
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Lab testJuly 12, 2014
BLOOD CHEMISTRY Value
SGOT/AST 36
SGPT/ALT 54
Renal Function
Ureum 20
Creatinine 0.8
CARBOHYDRATE
Random blood glucose 173
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Lab test - July 13, 2014Parameter Value
BLOOD CHEMISTRY
ELECTROLYTE
Sodium 159
Pottasium 4.47
Calcium 1.21
Chloride 128
ARTERIAL BLOOD GAS
Temperature 37.4
Hemoglobin 12.7
Result
pH 7.35
pCO2 47pO2 211
HCO3act 25
Base excess 1
ctCO2 60
O2Sat 100
O2CT 18
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Lab testJuly 16th, 2014
BLOOD CHEMISTRY Value
CARBOHYDRATE
Random blood glucose 136
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Parameter Value
BLOOD CHEMISTRY
ELECTROLYTE
Sodium 175
Pottasium 2.71
Calcium 1.4
Chloride 141
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BLOOD CHEMISTRY Value
SGOT/AST 101
SGPT/ALT 164
Renal Function
Ureum 52Creatinine 1.4
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Parameter Value
URINE
COMPLETE
Glucose (-)
Protein One (+)Bilirubin (-)
Urobilinogen One (+)
Ph 6
Density 1015
Smear blood Three (+++)Keton (-)
Nitrit (-)
Leucocyte (-)
Sediment
Leucocyte 0-1Erythrocyte 7-10
Epithel (+)
Silinder (-)
Crystal (-)
Bacteri (-)
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InterpretationJuly 11th, 2014
Cereberal edema with subarrachnoidhemmorrhage and mild cereberalcontussion at frontal sinistra
Multiple fracture at os. Frontalis withminumum depressed fragment, cranialbase fracture, left temporal
Left retro orbital no fracture fragment seen
Bilateral maxillary, ethmoidal, frontal, andsphenoid hematosinus
Left hematomastoid
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Facial CT Scan 3DJuly 15th, 2014
Multiple fracture at os frontal with minimumdepressed fragment, fracture line thatelongates from left frontal to left orbital rimdirection until left maxillary sinus anterior walland left lamina cribiformis, no fracturefragment seen in left retro orbita.
Bilateral maxillary, ethmoidal, frontal, andsphenoid hematosinus
Basis cranii fracture
Subarachnoid hemorrhage Left hematomastoid
No fracture seen in cervical CV 1-6
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EKG
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Resume
A patient, male, 30 y.o., came with chief complaint ofloss of consciousness for 30 minutes after he fellfrom a 5-meter height building construction. Patientexperienced severe headache and during in the ER,the patient vomited 4 times with total + 600mL
gastric juice with blood discharged. The patient denied any history of past illness,
smokes cigarette regularly and drinks alcoholoccasionally.
From the physical examination there is hematomaa/r frontalis sinistra, headache as a sign ofintracranial pressure increase. From lab test, thepatient has leucocytosis, increased liver enzyme,hyperglycemia, hypernatremia, hyperchloremia, andanemia.
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From the CT-scan were found Subarachnoid
haemorrhage with cerebral edema. Bilateral
maxillary, ethmoid, frontal, and sphenoid
sinuses fractures with haematosinus.
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Diagnosis
Clinical : Headache
Topis : Subarachnoid
Etiology : Trauma
Pathology : Haemorrhage
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Os patella dextra fracture
Bilateral maxillary, ethmoid, frontal,
sphenoid sinus fracture
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Assessment
A patient, male, 30 y.o., capitis trauma,
anhydrosis, multiple vulnus laceratum
and os patella dextra fracture
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Treatment
Collar neck
IVFD RL 1000cc/24hours
Omeprazole 2x40mg IV
Ceftriaxone 2x2 g IV
Vit C 1x400mg IV
Mannitol 250cc4x125cc
Tramadol 2x50mg/drip
Metilprednisolon 2x125mg
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Follow up12/07/14 13/07/14 14/07/14 15/07/14 16/07/14 17/07/14
Vomits
300cc,
dizzy, pain
fullout the
body
Left shoulder
pain, dizzy,
post
operation
wound pain
110/70;116;
34;37
150/100;140
;22;37
157/104;138;
22;38
160/99;108
;24;38
147/93;106
;25;38.2
125/83;161;
43;39.7
GCS 14
E3V5M6
GCS 15
E4V5M6
GCS 14
E3V5M6
GCS 14
E3V5M6
GCS 14
E3V5M6
GCS 14
E3V5M6
NGT 300cc
dark brown
NGT 425cc
cloudy
Motoric
weakness in
all
extremities
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Introduction
Primary goalprevention of secondary
brain injury
Adequate O2 and BPgood perfusion
= limiting brain damage
ABCDE + identify mass lesionCT
Scan
CT Scan Should Not Delay Referal!
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SCALP
Skin
Connective Tissue
Aponeurosis (galea aponeurotika)
Loose areolar Tissue
Subgaleal haematomblood loss in infants
and child
Pericranium
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Bleeding of the Scalp
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The Cranium
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The Meninges
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The Brain Frontalexecutive,
emotions, motor, speech
Parietal - sensory functionand spatial orientation
Temporal - memory
functions
Occipital - vision
Brainstem
Midbrain - RAS
Pons - RAS MedullaCardiorespiratory
Cerebellumcoordination
and balance
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Tentorium
Supratentorial Fossa cranii anterio and media
Infratentorial Fossa cranii posterior
Midbrain Tentorial hiatus
Connects brain hemispherepons and medulla
N.IIIalong tentorium edge Medial Temporal lobe (Uncus) herniation
dilated pupil
T t i
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Tentorium
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Monro-Kellie Doctrine
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Epidemiology
In USA, 1,5 million cases/year
50.000 +, 80.000-90.000 longterm
neurologic impairment
Head trauma is the main cause of deathin traumatic patients
Main cause of head trauma : fall and
traffic accident (80%)
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Types of Injury
Injuries on head trauma is classified into 2 :
Primary injuryanatomy and physiology
disorder caused directly by trauma
Secondary injuryextention of primaryinjuryswelling, hypoperfusion, hypoxemia,
ICP increase)
Acute phase management : to prevent
secondary injury
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Recucitation priority
Hypotension caused twice the death
compared to hypoxemiaGoal: sistole
90
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Classification of Head Injury
Based on mechanism of injury: blunt(automobilecollisions, fall, blunt weapon) or penetrating
(gunshot, stab)
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Basal Skull Fracture
Sign:
Racoon eyes (periorbital ecchymosis)
Battle sign (retroauricular ecchymosis)
Rhinorrhea & otorrhea (CSF leakage)
N. VII and N. VIII dysfunctionN. VII
recovery prognosis better than N. VIII
Management of Minor Brain
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Management of Minor Brain
Injury (GCS 13)
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Management of Moderate Brain
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gInjury
(GCS 9-12)
Management of Severe Brain
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gInjury
(GCS 8)
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Summary of Management
Minor: Neuro PE & CT (if needed)
Moderate: Minor+ CT, Close
Observation,baseline blood work, CT
follow up Severe: Moderate+ Therapeutic agent
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Therapeutic Agent
IV fluid isotonic Prevent Hypovolemia
Hyperventilation
As indicated, normocapnia preferredAnticonvulsant (fenitoin) Inhibit brain recovery
Prolong seizure = secondary brain injury
Manitol (ICP in acute phase)
Barbiturat (ICP in chronic phase)
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Surgical Management
Indications: Scalp wounds - Wound Toilet, Hecting
Depressed Skull Fractureoperative
elevation Intracranial Mass Lesioncraniotomy
Penetrating Brain Injuryneurosurgicalremoval
Partially exteriorized object SHOULD NOTBE REMOVE!!vascular injury, intracranialhemorrhage
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